Inspection on 06/02/06 for Brymore House

This inspection was carried out on 6th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brymore House 27/02/07

Brymore House 27/09/05

Brymore House 31/03/05

Brymore House 28/10/04

Brymore House 14/01/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brymore House Brymore House Residential And Nursing Home 243 Baring Road Lee London SE12 0BE Lead Inspector Ornella Cavuoto Unannounced Inspection 10 13th February 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brymore House Address Brymore House Residential And Nursing Home 243 Baring Road Lee London SE12 0BE 020 8851 4592 020 8851 4207 brymorehouse@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Marjoram Mrs Mary Marjoram Mrs Sharon Feleppa Care Home 46 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0), of places Terminally ill (0) Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 30 patients Elderly, frail persons aged 60 years and above (female) and 65 years and above (male) 20 residents Persons aged 55 years and above, and persons suffering from dementia 14 of the beds registered as `nursing` can be used for either patients or residents - maximum of 46 patients and residents combined To include one person with palliative care needs Up to 5 patients, aged 60 or above if female or 65 and above if male, for intermediate care using bedrooms 3-7 Providing that the intention to create an additional, dedicated lounge/seating area is completed by December 2005 27th September 2005 Date of last inspection Brief Description of the Service: Brymore House is located on a main residential road and is about 5 minutes walk from Grove Park railway station and the local shops. The house is a large detached property with its own drive. There is an attractive enclosed garden and patio at the rear of the house. The accommodation is on three floors with a shaft lift providing level access to all parts of the home. The registration is for a maximum of 45 service users, up to 30 of who may require nursing care. There is also one place for palliative care and up to five places for intermediate care. There is currently building works going on to complete a dedicated space for the intermediate care, the majority of which has been completed. The manager is a Registered General Nurse and has considerable years of experience. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over a day and half. The registered manager was present for the duration of the inspection. In addition, eight service users and two relatives were spoken to and eight staff members. Other inspection methods included inspection of care records and a tour of the premises. What the service does well: What has improved since the last inspection? The home has ensured that for all potential service users moving into the home a full needs assessment has been obtained. The home has made improvements around the recording of the administration of medication. Records that were inspected were all accurate. Photographs of service users have now been attached to all individual service user medication records as a measure to prevent medication errors from occurring. There have been some improvements around the way activities carried out with service users are recorded to try to ensure that service users are involved Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 6 in activities that they enjoy and that suit their individual preferences and interests. The home has made the complaints policy more accessible to service users, relatives and representatives by placing the policy that is on display within the home in a place that is more visible and writing it in larger print. The home has taken measures to ensure that staff are made more aware of the issues involved in adult abuse and their responsibilities in respect to adult protection by providing in–house training sessions as well as arranging for staff to attend external training courses. The home has ensured that whilst building works have been carried out that the drive way of the home has been kept clear, providing easy access for service users, their relatives and also, if required, emergency services. Also, the home has ensured that overall the disruption to service users has been kept to a minimum. What they could do better: The home needs to ensure that the Statement of Purpose and Service User Guide are updated and that all service users are issued a copy of the updated version of the Service User Guide. The home needs to ensure that all service users are issued a contract outlining the terms and conditions of their stay within the home. Service users need to sign this, be given a copy and a copy kept on their files. The home needs to ensure that the social and personal care needs of service users are addressed more effectively within their care plans with more information being included on their individual preferences and interests. Furthermore, the home needs to ensure that care plans are signed by service users, their relatives or representatives where appropriate to indicate their involvement in the care planning process and monthly reviews of care plans need are carried out. The home needs to ensure that in particular for those service users in intermediate care who are aiming to return home, that their ability to selfadminister medication needs to be looked at as part of their care plan and risk assessment and that those service users that can administer their own medication are encouraged to so. All service users need to be sensitively consulted around their personal wishes for death and dying and this needs to be recorded as part of their care plans. The home still needs to ensure that there is further consultation and feedback is obtained from service users about their individual leisure interests and also that all care staff are involved in undertaking activities with service users. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 7 The home needs to ensure that their Access to Information policy is revised to include reference to the Data Protection Act 1998. Also, the home must make arrangements to inform service users, their relatives and representatives of how to access external advocacy services. The home’s complaints policy needs to be revised to ensure that timescales are included for the investigation of complaints and for when service users, relatives and representatives are to be informed of the outcome. All service users need to be issued a copy of updated policy. The home must ensure that when recruiting staff that all the required documents are in place prior to staff members being allowed to start working within the home. All staff need to have an annual appraisal to help to identify individual training needs and an annual training plan needs to be drawn up. Staff also need to be given regular supervision. The home still needs to develop an effective quality assurance system that involves consultation with service users. The home must ensure that all aspects of fire safety are carried out to ensure the health, welfare and safety of service users is maintained. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 6 Potential service users do not currently have the information they need to make an informed choice about where to live. Not all service users have been issued with a written statement of terms and conditions. All service users have had their needs assessed prior to moving into the home. Service users, relatives and representatives know the home will meet their needs. Service users in intermediate care are generally helped to maximise their independence and return home. EVIDENCE: The Statement of Purpose and Service User Guide were inspected. Both documents are in need of being reviewed and updated. The updated copy of the Service User Guide should be dated and issued to all service users living within the home (See Requirements). At present only self- funding service users receive a written contract outlining terms and conditions of their stay with the home. It was specified that a contract should be issued to all service users. A draft contract was drawn up Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 10 during the inspection that included all the information required by the standard. However, this needs to be issued to all service users who must sign it, a copy given to them and a copy also kept on their file (See Requirements). The files of those service users who had only recently been admitted were inspected and all were found to include a full needs assessment. Subject to a previous requirement that service users should only be admitted to the home on the basis that a full needs assessment is obtained this has now been met. The majority of staff at the home have worked there for many years and individually and collectively are both experienced and qualified. There was also evidence that staff have received training to ensure that the specific needs of service users are met including palliative care training, dementia and challenging behaviour and intermediate care training. Therefore, service users and their representatives know the home is able to meet their needs. The home has recently had work carried out to provide a dedicated space for five intermediate care beds with additional facilities such as a gym and small kitchen for comprehensive recovery and therapeutic programmes to be undertaken with service users including support with activities of daily living and mobility. Although, at the time of the inspection work was still being carried out to complete the gym area, there was evidence to indicate that the home is providing an effective intermediate care service. There are good links with specialised staff including a physiotherapist, occupational therapist and social worker from Lewisham’s Intermediate Care (LINC) team and a consultant who regularly visits the home. The home is also working towards ensuring that an integrated approach is used between the LINC team and the home’s nursing and care staff to maximise the support received by intermediate care service users. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 &11 Care plans still do not set out in sufficient detail service users’ personal and social care needs. Where appropriate, service users still need to be encouraged to take responsibility for their own medication. Service users feel they are treated respectfully and their privacy maintained. There still needs to be more consultation with service users, family or friends around their personal wishes and instructions at the time of death. EVIDENCE: Six service user care plans were inspected. A previous requirement that the care plans should set out in detail the personal and social care needs of service users has not been met. Only two of the care plans looked at included some details around the preferences of service users around personal care routines and recording of personal care charts for individual service users was inconsistent. Three of the care plans did include some detail of the social background of service users. However, only one service user had a Life Review form which is aimed at developing a social care plan tailored to individual service users’ needs and this was only partially completed. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 12 In addition, service users, a relative or a representative had signed none of the care plans inspected to indicate their involvement in the care planning process. The majority of the care plans had not been reviewed monthly (See Requirements). A previous recommendation that clip folders should be used to store additional information on service users such as the Life Review forms, hospital appointments has been met making this information more easily accessible. The folders are colour coded to denote which key worker team have been allocated to work with them. The home has robust policies and procedures for dealing with medication and self-administration of medication. Only trained staff administer medication. A previous requirement that the system in place for monitoring the administration of medication needs to be used consistently with staff ensuring that all medication dispensed is signed for has been met. A sample of MARS (Medication Administration Record) sheets was inspected and all were found to be accurate. Also, the previous requirement, that individual service user medication records should have a photograph attached has been met. However, in respect to the previous requirement that where appropriate service users should be encouraged to take their own medication within a risk management framework this has not been met. In respect to intermediate care service users, it was reported that an assessment is carried out around their ability to self-administer their own medication prior to admission; however, there was no evidence to indicate this had been completed with service users and it is recommended that this is done in future. (See Recommendations). It was evident that the privacy and dignity of service users is maintained. Service users spoken to confirmed that staff assist them appropriately with personal care. All service users spoken to and observed were well dressed and well-groomed and service users confirmed that they are able to choose their own clothes. Also, all bedrooms have a telephone line so that service users can have the use of their own telephone if they wish. Only two of the six service user plans looked at included details around service users personal wishes and instructions around death and dying. Continued efforts need to be made by staff to sensitively consult with service users, family members and representatives where appropriate on this issue (See Recommendations). Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, & 14 Further consultation and feedback needs to be carried out with service users to ensure that they are able to participate in activities that match their personal preferences and interests. Service users need to be provided with more information around accessing advocacy services to ensure they can fully exercise choice and control over their lives. EVIDENCE: The home’s activities co-ordinator continues to work on ensuring that service users are involved in-group activities and to ensure that individual time is also spent with service users. The co-ordinator maintains a record, which was inspected of all the activities that are organised, who participated and a brief note on whether the activity was enjoyed or not. A note is also made of those service users with whom individual time is spent. There have been no changes in the range of activities that are currently offered to service users which include reminiscence, arts and crafts, knitting and crochet, bingo, board games and puzzles although the co-ordinator mentioned that herself and some of the carers are intending to do some training to enable them to conduct aromatherapy sessions with service users. Purchasing a DVD /video machine to enable service users to watch old films has also been discussed. In addition, various musicians and singers are brought into the home to entertain service users. One relative spoken to commented in respect to activities “There are a Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 14 lot of things going on” whilst another relative said, “There is a lot of involvement and mental stimulation.” However, a service user spoken to stated although they enjoyed living at the home very much they would like to go out more. It is evident there still needs to be more consultation carried out with service users about activities provided by the home and feedback obtained about any other activities they would like to be arranged to ensure they are all given opportunities to partake in a range of recreational and leisure activities suited to their needs and interests in and outside the home (See Requirements). In addition, it is important that all care staff are involved in carrying out activities and spending individual time with service users and this could be achieved by using the home’s key worker system more effectively (See Recommendations). In respect to autonomy and choice one service user spoken to commented, “No one tells you what time to go to bed or to get up, I wander about here as I like”. In addition, it was evident that service users can bring in personal possessions with them. All service user rooms inspected were personalised and generally very homely. In respect to service users having access to personal records although the home reported that service users can see their records at anytime and the personal files for intermediate care service users are kept in their rooms the home’s policy in respect to Access to Information needs to be reviewed and drawn up in accordance with the Data Protection Act 1998. In addition, the home needs to ensure that service users, relatives and representatives are given access to information about how to contact external advocacy services who will act in their interests if required (See Requirements). Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 The home’s complaints policy needs to be reviewed to ensure service users are clear about the home’s responsibilities in investigating complaints. All staff working within the home must receive training on adult protection procedures and abuse awareness. EVIDENCE: The previous requirement that the home’s complaints policy must be made accessible to service users and that all service users are made aware of their right to complain has been partially met in that the complaints policy displayed within the home has been placed in a more accessible position for service users, relatives and representatives and it has also been written in larger print. However, the policy itself needs to be revised to include the timescales for the investigation of complaints and to inform service users, relatives or representatives where appropriate of the outcome. Furthermore, the updated complaints policy needs to be included in the Service User Guide and this must be issued to all service users (See Requirements). The home has had one complaint since the last inspection that was made via the Commission for Social Care Inspection (CSCI) and has been concluded. There were no complaints recorded in the home’s complaints log. All service users and relatives spoken to were satisfied with the service they are receiving by the home. The previous requirement in respect to all staff receiving training in adult protection and being made aware of the home’s adult protection policy has been partially met. It was reported by the registered manager that since the Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 16 last inspection the home has obtained a training video produced by the Department of Health that has begun to be used to increase staff awareness around adult abuse and procedures to be followed. The registered manager has also arranged for staff to attend training courses on adult abuse that some staff have completed whilst others are still waiting to attend. Some evidence of this was seen and staff spoken to did have awareness in this area and three confirmed they had completed training. However, it is still important that all staff receive training (See Requirements). In addition, it is advised that the registered manager obtain a copy of The London Borough of Lewisham’s Adult Protection Procedure for staffs’ information (See Recommendations). Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 21&22. Despite building works service users continue to live in a safe, well -maintained environment. Although building work is being carried out on the home restricting access to communal areas, overall the disruption to service users has been kept to a minimum. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they need to maximise their independence. EVIDENCE: The home is still having some building work carried out to complete work in relation to the intermediate care service as well as building a new kitchen and relocating two service users bedrooms and an office. However, the disruption to service users has been kept to a minimum and the home remains safe, accessible and comfortable. Overall the home is well maintained and is suitable for its stated purpose. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 18 The work being carried out has also meant that one of the lounges has had to be temporarily closed to service users. The dining area space has had to be modified to accommodate more service users and access to the garden is restricted. Yet, overall the home still has sufficient communal space to accommodate the needs of service users with a large spacious lounge that is homely and furnishings that are domestic in character. Those service users and relatives spoken to did not express any concerns about the building work. It was reported the work is due to be completed in approximately eight weeks. A previous requirement was stated that whilst building work is being undertaken the drive way of the home must be kept clear at all times to give access to service users and those visiting the home. Also, to ensure that in the event of an emergency the home is easily accessible for the emergency services to approach the home. This has now been met. The driveway was clear on the day of the inspection and it was reported that all workmen have been given instructions not to block the driveway. The home has two bathrooms and toilets on each floor providing sufficient facilities for service users. In addition, all service users who receive nursing care are placed in bedrooms that have en –suite toilet and wash- basins. The majority of the home is wheelchair accessible including communal areas, bathrooms toilets and bedrooms except for those rooms that are specifically allocated to service users admitted to the home for residential care on the first and second floors. The home has a passenger lift giving access to all floors. There are also aids, hoists and assisted toilets and baths that are capable of meeting the assessed needs of service users. In respect to a previous recommendation that the home should ensure that an assessment of the premises and facilities should be undertaken by an occupational therapist this was discussed with the registered manager who reported that the home had been unsuccessful in finding an organisation to carry out the assessment. The home does liaise with a range of health professionals to ensure that the individual needs of service users are effectively met and where required this would include advice from an occupational therapist. Consequently, this recommendation is not to be restated. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 There are sufficient numbers of staff on duty with the required skills to meet the needs of service users. Over 50 of the care staff have obtained the National Vocational Qualification (NVQ) Level 2 in care. Service users are not being completely supported and protected by the home’s recruitment practice. Staff receive regular training opportunities although the home needs to ensure that a training plan is drawn up to ensure the training needs of staff are addressed. EVIDENCE: The home’s rota was examined which accurately reflected the numbers of staff on duty the day the inspection was carried out. It was also evident through observation that there was more than sufficient staff available to meet the needs of service users. The home ensures that there three qualified nurses and eight care staff on duty on an early shift, two nurses and seven care staff on an afternoon/evening shift and one nurse and four care staff on at night. It was reported that to date 62 of the care staff have obtained a NVQ Level 2 in care meeting the target that at least 50 of staff should have obtained this qualification or an equivalent by the end of 2005. Of those seven care staff spoken to six were qualified. Further staff are also being supported to complete the NVQ Level 2 in care. Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 20 A previous requirement that staff should not be allowed to commence work in the home until all required documents have been obtained has not been met. The documents of two staff due to start work within the home were inspected and it was identified that only a verbal reference had been obtained for one of the staff members instead of the required two written references (See Requirements). It was reported that the home has access to training via the Care Home Support Team and also Lewisham Consortium. In respect to manual handling a staff member is to be trained as a trainer to enable staff to have this training updated in –house. Evidence was seen from staff files that staff have had some mandatory training and also more specific training to meet individual service users needs. However, there is not presently an annual training plan in place and there was no recent evidence that annual appraisals have been carried out with staff. This would further facilitate the identification of training needs for individual staff (See Requirements). Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 &38 The home is well run and managed by a competent and experienced person. The home still does not have an adequate and effective quality assurance system in place to ensure the home is run in the best interests of service users. Service users financial interests are not being completely safeguarded. Staff are not presently being regularly supervised. The home does generally promote and protect the health, safety and welfare of service users but fire drills need to be carried out at different times. EVIDENCE: The registered manager has been working at the home since 2001. She is a qualified nurse and has also completed the NVQ Level 4 in management and is a member of the Chartered Institute for Managers. She is very committed to training and regularly attends conferences and training days to update her knowledge and skills. It was clearly evident from observations between the Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 22 manager staff and service users that they find her approachable and she is also very knowledgeable about staff and service users needs. A previous requirement that an effective quality assurance system based on seeking the views of service users and reporting the findings back in a report which is then made available to service users, relatives, their representatives, other stake holders and also to CSCI has not been fully met although it was reported that a new questionnaire is being developed. It was also reported that in respect to a previous recommendation that the registered provider should look into introducing an externally recognised professional quality assurance tool that a quality assurance system developed by the National Care Homes Association is being looked into. Both are to be restated in this report (See Requirements and Recommendations). In respect to service users’ money it was reported that where possible the home encourages service users to manage their own finances or relatives to do this on their behalf. The home only has responsibility for managing one service user’s personal allowance as the service user does not have any next of kin and the arrangement was already in place in the home where the service user was living previously. The administrator takes overall responsibility for managing the account that has been set up by the home and is non -interest bearing. A record of all financial transactions is kept on the home’s computer. However, receipts are not presently kept by the home and copies issued to the service user in respect to transactions that take place. This needs to be done (See Requirements). A previous requirement that staff must receive regular supervision has not been met. Although, there was some evidence that supervision sessions have been held with staff this has only recently been initiated with records indicating that staff have only had one supervision session carried out with them since the last inspection. The registered manager reported that a new supervision form is to be developed and all staff are to be issued with a supervision contract (See Requirements). A previous recommendation that staff meeting minutes need to include all those in attendance and action to be taken on points raised has been completed. The home has health and safety policy and procedures in place. A sample of maintenance certificates were seen including that of the home’s gas boiler, electrical equipment, the passenger lift and for hoist equipment. There was evidence that water temperatures are regularly checked to prevent against the risk of scalding and also tested for the risk of Legionella. A building and fire safety risk assessment are both in place. However, in respect to fire safety the fire book was inspected that indicated that the last fire drill conducted was in May 2005. Also, the times of the drills have not been consistently recorded to ensure they are carried out at different times to include night staff. A record of Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 23 the testing of call points was not available. It was reported that the maintenance man carries these out. This will be checked at the next inspection. Furthermore, a fire safety inspection had not been carried out on the newly built intermediate care section of the home. The registered manager did report following the inspection that this has been inspected by the LFEPA but evidence of this needs to be provided to CSCI (See Requirements). Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 X 2 Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4&5 Requirement Timescale for action 31/08/06 2. OP2 5 (1) (b) 3. OP7 15(1)&(2) (c)&(d) 4. OP7 15(1)(b) The registered person must ensure that the Statement of Purpose and Service User Guide are updated and a copy of the updated Service User Guide is issued to all service users. The registered person must 31/08/06 ensure that all service users are issued with a contract outlining the terms and conditions of their stay within the home, which they sign and a copy kept on their individual files. The registered person must 31/08/06 ensure that service user plans sets out in detail the action that needs to be taken by staff to ensure all aspects of personal and social care needs of service users are met. Also, that the care plan is signed by the service user, their relative or a representative where appropriate to indicate their involvement in the care planning process. (Previous timescale of 31/01/06 not met) The registered person must 30/04/06 ensure that service user plans DS0000007010.V281179.R01.S.doc Version 5.1 Brymore House Page 26 5. OP12 16(2)(m) &(n) 7. OP14 12(2)&15 (2)(a) 8. OP16 22 9. OP18 13(6)&18 (1)(c)(i) are reviewed on a monthly basis. The registered person must ensure that service users are consulted and feedback obtained on social activities and leisure interests that are provided to ensure that they are given opportunities to partake in recreational and leisure activities in and outside of the home that are suited to their needs, preferences and capacities. Further, that information about activities to be provided is circulated to all service users. (Previous timescale of 31/01/06 partially met) The registered person must ensure that the Access to Information policy is revised to include reference to the Data Protection Act 1998. Also, arrangements are made to ensure that service users, relatives and representatives are given information on how to access external advocacy services if required. The registered person must ensure that the complaints policy is revised to include timescales for the investigation of complaints that are received by the home and of when service users, relatives and representatives will be informed of the outcome. All service users must be given a copy of the updated policy. (Previous timescale of 31/12/05 partially met). The registered person must ensure the safety and protection of service users from forms of abuse by ensuring all staff working within the home are aware of adult protection policies and procedures (including DS0000007010.V281179.R01.S.doc 31/08/06 31/08/06 30/06/06 31/08/06 Brymore House Version 5.1 Page 27 10. OP29 19 & Sched 2 11. OP30 18 (1) (c) 12. OP33 24 13. OP35 16 (2) (l) 14. OP36 18 (2) 15. OP38 23 (4) (e) whistle blowing) and have received training in this area. (Previous timescale of 31/01/06 partially met) The registered person must ensure that staff do not begin work in the home until all documents required by regulation are in place. (Previous timescale of 31/01/06 not met) The registered person must ensure that all staff receive an annual appraisal to identify individual training needs and that an annual training plan is drawn up. The registered person must ensure that an effective quality assurance system based on seeking the views of and reporting back findings to service users, their families and other stakeholders is in operation at the home. Previous timescale of 31/03/05 & 31/01/06 partially met) The registered person must ensure that where responsibility for the management of service users’ money is taken that a receipt is issued to the service user for all financial transactions that are carried out and a copy of the receipt is kept by the home. The registered person must ensure that all staff receive regular individual supervision and that each session is formally recorded. (Previous timescale of 31/01/06 not met). The registered person must ensure that -Regular fire drills are carried out at different times to ensure all staff are involved and these DS0000007010.V281179.R01.S.doc 30/04/06 30/09/06 30/09/06 30/04/06 30/09/06 30/06/06 Brymore House Version 5.1 Page 28 times are recorded. - Evidence is sent to CSCI that the intermediate care section of the home has been inspected by the LFEPA (Local Fire Authority). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP11 Good Practice Recommendations The registered person should ensure, where appropriate, that service users are involved in the risk assessment of their ability to take responsibility for their own medication The registered person should try to ensure that all service users and where appropriate relatives/representatives be consulted about their wishes and instructions at the time of death and recorded as part of service users’ care plans. The registered person should try to ensure that all care staff are involved in the undertaking of activities with service users and that the home’s key worker system should be used to ensure this is carried out effectively. The registered person should try to obtain a copy of the London Borough of Lewisham’s Adult Protection policy for the information of staff. The registered provider should consider implementing an externally recognised professional quality assurance tool in the home. 3 OP12 4 5 OP18 OP33 Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brymore House DS0000007010.V281179.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!