Inspection on 12/10/05 for Rivendale Lodge EMI Care Home

This inspection was carried out on 12th October 2005.

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

Rivendale Lodge EMI Care Home 10/05/07

Rivendale Lodge EMI Care Home 30/01/07

Rivendale Lodge EMI Care Home 11/05/06

Rivendale Lodge EMI Care Home 17/05/05

Rivendale Lodge EMI Care Home 19/01/05

Rivendale Lodge EMI Care Home 03/06/04

Similar services:

Springfield House

The Old Downs Care Home

Ridgemount

Lawrence House

Anchorstone Services Limited

Lulworth Residential Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Brook Hill Rest Home Brook Hill Rest Home 14 Prideaux Road Eastbourne East Sussex BN21 2NB Lead Inspector Judy Gossedge Unannounced Inspection 12th October 2005 11:45 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 Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 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. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brook Hill Rest Home Address Brook Hill Rest Home 14 Prideaux Road Eastbourne East Sussex BN21 2NB 01323 731575 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 Prashant Brahmbhatt Mr Sunjay Kumar Rai, Mr Ashish Sharma, Mrs Sylvia Barbara Giles Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is twenty-six (26). Service users must be older people aged sixty-five (65) years and over on admission. Service users with a dementia type illness only to be accommodated. The second floor accommodation is restricted to use by service users who are ambulant and can access their private accommodation independently. 17th May 2005 Date of last inspection Brief Description of the Service: Brook Hill is a residential care home for older people with dementia. It is situated in a residential area of Eastbourne. The home is a detached older-style building, on three floors standing in its own grounds. There are sixteen single and five double bedrooms sited on all floors, and a lounge and dining room on the ground floor. It is not purpose built and there is no passenger lift, but equipment is provided in the home to help service users up and down the stairs if required. All the bedrooms have a wash-hand-basin. The majority of bedrooms do not have en-suite facilities, but three bedrooms have a toilet and wash hand basin and of these three one also has a shower facility. Assisted bathing facilities are available in the home. There is a garden laid to lawn at the rear of the home. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours on 12 October 2005 and there were two Inspectors present during the inspection. This is the second statutory inspection of this year. Monitoring visits have also been carried out on 27 May, 13 June, 7 July, 8 September and 22 September 2005 to review compliance with requirements made following the last inspection. The CSCI have also met again with the proprietors for the home to discuss outstanding requirements and work in progress to meet ongoing requirements. As detailed in the last report the CSCI pharmacist also visited on 26 May 2005 and a response to the issues raised has been received. The CSCI detailed in the last inspection report that anonymous formal complaints had been received relating to the care provided in the home. These complaints were passed to East Sussex County Council Social Services Department to be considered under Adult Protection Procedures. The proprietors fully co-operated with the investigation, which has now been completed and steps have been undertaken to improve the quality of the care provided. Where issues are still to be addressed these are detailed in the report. There will be a further review of the situation in the home after six months. The CSCI will also still be monitoring during this period compliance with outstanding requirements and additional requirements made following this inspection. The CSCI also received a further complaint, which is detailed in the report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms, rotas and care records were inspected. Twenty service users were resident, but due to communication difficulties it was not possible to speak to all service users individually but a number were spoken to as part of the inspection process, and the opportunity was also taken to observe the interaction between staff and service users in the communal area. Four care staff, the cook on duty, the laundry assistant, the activities coordinator and the Administration and Policies Manager were spoken to. Comment cards were left following one monitoring visit for relatives and representatives to complete if they wished and six completed cards were received. Four relatives were also spoken with on the telephone after the inspection. There has been a significant period of change in the home with the Registered Manager leaving in October 2004 and an Acting Manager in July 2005. Currently there is not a Registered manager for the home and interim management arrangements in place include the Administration and Policies Manager (Acting Manager) and Deputy Manager working with support being provided by a former Registered Manager working for the Residential Recovery Service. The CSCI is still awaiting an application to register a manager for the Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 6 home, and the proprietors have stated that they are working to address this issue. The proprietors and the new management team have worked towards addressing the issues raised and there has been an improvement in a number of areas and these are detailed in the report. But there are still some significant outstanding issues that now need to be addressed. What the service does well: What has improved since the last inspection? Regular activities are now being facilitated for service users during the week, and more opportunities for service users to socialise with their relatives/representatives at events arranged in the home. But service users individual social care needs should be documented and considered within this process. Regular recorded visits by the providers to meet the requirements of Regulation 26 have commenced. Care staff now receive individual supervision alongside their staff meetings. Thirty-seven percent of care staff hold NVQ Level 2 or above in care. A rotating menu has now been put in place which details a choice at every meal. A number of new environmental improvements have been made including the installation of a new cooker, a new emergency call system and floor covering in the laundry. All staff are being taken through the new induction process introduced in to the home. A written health and safety policy is now in place. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 7 What they could do better: 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. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 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 Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 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, 5 and 6. There is detailed information available to be viewed and opportunities to visit the home prior to any admission. Service users are protected by the completion of a written contract/terms and conditions. Pre-admission procedures in place should be followed to ensure that service users care needs are identified and can be met in the home. Care staff should receive training in providing care to service users with dementia to ensure that they have the skills and knowledge to provide the appropriate care. EVIDENCE: A Statement of Purpose is now available to view. There have been some further additions to the content but it still does not detail all the required information. A Service Users Guide is now in place and this information is kept at the entrance of the home for people to read. Not all of the relatives were aware of inspection reports, but two were and confirmed they had received a Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 10 copy of the last report from staff in the home. It should be ensured that all relatives/representatives are aware of how to access the inspection reports. There is a detailed contract/terms and conditions in place to be used between the home and the service user. Three were viewed for new service users, one had been completed and two were in the process of being completed. These should be made available on or prior to admission and not completed afterwards. New service users are visited prior to admission to ensure individual service users care needs can be met in the home and to provide staff with information on the care to be provided. One relative commented they had had a detailed discussion with staff about the care needs of their relative. There were six new service users resident and their pre-admission information had not been fully completed, detail was limited and did not provide staff with the enough information to start to compile a detailed individual care plan. Not all staff have received guidance/training for providing care to service users with dementia. But it is understood that training has been booked and staff are due to attend this during November. Three of the relatives confirmed that they had had the opportunity to view the home prior to their relative moving in. One commented, My relative has only just gone into care but having viewed several homes prior to finding this one, I feel that this home surpasses most of the others I viewed. The staff and management are exceptional, not just in providing physical care but also in providing excellent and genuine, caring social interaction with the residents (something I saw in very few other care homes I visited) - The atmosphere and ethos of the home are excellent too. A place with a very positive attitude, which can only benefit everyone involved (staff, residents and families.) A further relative confirmed that ’I liked the happy atmosphere.’ Intermediate care is not provided in the home. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 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, 8 and 10. The information detailed in individual care plans need to be further developed to ensure that service users’ health, personal and social care needs are addressed. Staff do not have the appropriate guidance to meet all the care needs of service users. The care service users receive ensures that their privacy and dignity is maintained whilst resident in the home. EVIDENCE: A selection of the service users individual care plans was viewed. The information detailed on the care plans though greatly improved following previous visits still did not in all instances give clear guidance to staff of the care to be provided, service users health care requirements, dietary needs, social and leisure interests, and how any identified risks are to be managed. The care plans had not been reviewed for several months. These should be updated monthly and subject to regular review to ensure any changes in service users care needs are met. The regular recording of service users weights should continue to be developed. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 12 Staff were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. All of the completed relatives’ comment carers stated they were happy with the overall care provided and feedback from the relatives spoken to was that the overall care provided is good, and two relatives also said how happy their relative was in the home. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 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, 13, 14 and 15. There are opportunities for service users to participate in a range of activities to fulfil their social care needs. There is flexible visiting in the home and visitors are welcomed. Catering arrangements are in place to provide service users with choice and variety of meals. But dietary needs should be considered within the care planning process and recording maintained to ensure that all service users receive an adequate diet and enjoy a varied diet. EVIDENCE: Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 14 An activities’ co-ordinator is now working in the home for twenty hours, five days a week and a regular programme of activities is in place. A selection of the activities is run by the activities’ co-ordinator when working in the home, and some activities are lead by external entertainment/activities groups coming in to the home. Records viewed supported this. But there were some gaps where activities were not provided on the activities’ co-ordinators days off. The Administration and Policies Manager stated that it was the intention that other staff would eventually be designated to help run activities to cover these days. On the day of the inspection on arrival a number of service users were painting and in the afternoon there was a music and movement activity run by an external group. The lounge is decorated and personalised with some of the artwork service users have completed. During the summer months there was a summer fete which service users and their families were invited to attend. A firework and Halloween party is also planned at the end of October. Some relatives commented on the work staff had put in to setting up and arranging these events and of the proposed plans for the Christmas season. One visitor commented was taken out, another stated that their relative had been very active prior to coming in to the home and enjoyed going out for a walk. Although during discussion at the time of admission, staff had stated that they take service users out, this had not occurred for their relative as far as they were aware. Service users interests are currently not fully completed on the individual care plans. Feedback from all relatives is that there was flexible visiting and that staff are always very welcoming. When asked if they could see their relative in private three confirmed this was possible with two going to their relative’s bedroom. A further three stated it can be difficult at times to maintain privacy during their visit. Two of these felt that a more private area in the home would be welcomed where they could sit together during their visit with their relative. None of the service users at the time of the inspection handled their own financial affairs and a number had relative or advocates supporting them. Some of the bedrooms had been personalised with items from home. A rotating menu is in place, which was in the process of being seasonally varied. This details there is always a choice of main meal provided. Lunch on the day was liver or pork casserole, bread and butter pudding, yogurt or icecream sponge roll. One of the main meals provided was not as detailed on the menu, which it was stated was due to the ingredients not being delivered as requested. Some service users were assisted with their meal in the dining room. One service user was sitting up in their bedroom on the first floor and had been given their lunch to eat in there. This service user was observed to be having difficulty in eating their meal and using the cutlery provided All care staff were downstairs and this was raised with the staff on duty to ascertain if assistance should provided. Assistance with meals was not recorded as a care need in the service users care plan. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 15 Records of service users dietary likes and dislikes have improved since the last inspection, but records of food consumed individually by each service user had not been maintained in all cases and so it was not possible to evidence a varied and adequate diet for all service users. One relative who had had the opportunity to observe tea on occasions whilst visiting commented they felt the tea menu was not very varied, that their relative enjoyed their food but had a lot of sandwiches, ice-cream sponge roll and tinned fruit for their tea. Another relative who had also observed tea confirmed that there was a choice and that the food was well presented. During one monitoring visit to the home service users were observed to have chosen the option of a cooked breakfast, which has been added to the breakfast menu. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 16 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 and 18. There is a complaints procedure in place, which enables service users and their representatives to raise any concerns that they might have. All staff have not received guidance/training to ensure that service users are protected from abuse. EVIDENCE: There is a detailed complaints policy and procedure in place. One complaint had been received by the home, had been dealt with by the previous Acting Manager the records of which were not available to view during the inspection. Not all the relatives confirmed a knowledge of the complaints procedure, two stated they had been given the information by staff. It should be ensured relatives/representatives are made aware of where to reference the complaints procedure. But all relatives felt it was an environment where they would feel comfortable if necessary to raise any issues. None had raised a formal complaint but one had raised a concern relating to the care provided which they felt staff in the home had dealt with appropriately. The CSCI received an anonymous complaint relating to elements of the care provided to service users at Brook Hill. After investigation the complaint was upheld. The CSCI detailed in the last report that anonymous formal complaints had been received relating to the care provided in the home. These complaints Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 17 were passed to East Sussex County Council Social Services Department to be considered under Adult Protection Procedures. The Acting Manager confirmed prior to the last inspection in May that staff had been re-issued policies and procedures in relation to vulnerable adults. There have been a number of staff changes since the last inspection in May. The Administration and Policies Manager stated that all staff are now being taken through the new induction procedures just introduced in to the home and that the Protection of Vulnerable Adults will be a subject covered within this. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 18 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, 23, 24, 25 and 26. The standard of the environment varies and an ongoing maintenance programme needs to be put in place to ensure the environment provides service users with a safe, attractive and homely place to live. The home is clean with the majority of the home free from odours. EVIDENCE: A maintenance person has been appointed and staff referred to a general maintenance book in place to record items for attention. There are a number of areas in the home starting to show some evidence of wear and tear and it was not possible to evidence an ongoing maintenance plan in place for the periodic redecoration of the home, repairs or replacement of furnishings and fittings. Some new equipment has been purchased such as a new cooker, stair lift, emergency call system and laundry equipment. The external décor of the home is poor and the proprietors have previously stated that work is to be carried out on the windows, which has not yet been Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 19 completed. One relative stated they were concerned at the standard of the external décor and windows. There are sixteen single bedrooms of which five do not meet the minimum space requirements, and five double bedrooms on all floors in the home. Access to the second floor is by way of a steep stairway with no alternative means of escape in case of a fire. The present registration states that service users accommodated on this floor should be fully ambulant. The care needs of the service user at present living on that floor should be reviewed on a regular basis to ensure their safety and that their care needs continue to be met. In general the bedrooms are well decorated, and some displayed service users individual styles and interests. Bedrooms are not furnished to meet minimum standards, although some new furnishings have been purchased since the last inspection. Bedroom doors are not fitted with a lock. If a lock and furnishings are not provided due to health and safety issues specific to individual service users then a risk assessment should be undertaken, recorded and available to view. Night-lights have been purchased instead of providing a bedside light. This should be reviewed and a bedside light be provided if this is highlighted to meet individual’s care needs. Not all bedrooms had a rubbish bin and it was not apparent where staff threw away their disposable aprons and gloves. A new emergency call system has been fitted in the home since the last inspection and all bedrooms now have an emergency call bell system. The service user observed sitting in their bedroom on the first floor during the visit was unable to reach this facility. The Inspectors raised this with staff on the day that the call system should be accessible, or if the service user could not use this facility what other checks of this service user to ensure their health, safety and welfare were in place. One visitor stated that their relative’s bedroom was excellent with a good view. Another visitor said their relative had a nice bedroom. Service users are unable to control the temperature in their own bedrooms. At the last inspection in May the Inspectors found that one service user’s bedroom felt cold and the service user also commented their bedroom was cold. This was reported at the time to the Acting Manager for an immediate resolution. The proprietors subsequently confirmed that supplementary heating would be provided whilst further work is completed on the main heating system to resolve this issue. A sample of seven wash hand basins and baths used by service users were tested, five were satisfactory but for one the temperature was 25 ° C and for another there was no hot water. This has been an ongoing issue in the home and was reported to the Administration and Policies Manager and an Immediate Requirement form was issued. It was not possible to evidence so confirmation of work completed to resolve these issues has been requested. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 20 The proprietors have subsequently confirmed a plumber has visited the home to look at the issues raised and at the time of the visit everything was satisfactory. Bathroom facilities are provided throughout the home. However most service users use the assisted bathroom on the ground floor. The home does not provide sufficient toilets throughout the building. The ground floor where most of the service users were observed to spend a significant part of their day has limited toilet facilities. This has been an ongoing requirement following the last three inspections and is understood that both these issues will be addressed within further developments of the home. Evidence will need to be provided to confirm that the home meets the Water Supply Regulations 1999. There is not a passenger lift in the home, but it is understood that the proprietors are arranging for one to be put in the home shortly. Currently a new stair lift has been fitted and is available to service users unable to use the stairs. It is required that when in use a risk assessment is undertaken and recorded to ensure individual service user’s safety. There is one lounge and dining area on the ground floor. The majority of the service users congregate during the day in these areas. The small additional lounge area although it is understood is still accessible to service users has now also been made into a staff area where staff can make snacks and hot drinks. The floor finish in the laundry is now readily cleanable. Part of the complaint the CSCI received detailed concerns that service users were wearing other service users clothes or their clothes were going missing. A system to sort clothes in the laundry area and ensure all items were named was to be put in place to resolve this issue. During the inspection, the clothes of a service user were seen in the bedroom of another service user and a selection of clothing seen in the laundry were not all named. The home was clean and odour free other than one bedroom where there was a very strong smell of urine, and one bath seat was covered in faeces both of which were reported at the time to the Administration and Policies Manager. Recording of routine fire checks carried out in the home were viewed and it was not possible to evidence all the checks that had been completed. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 21 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 and 30. Staffing levels were sufficient on the day to ensure that service users needs are always appropriately met. Robust recruitment policies and procedures are in place but need to be followed in order to protect service users. Satisfactory induction training to meet requirements has been introduced to ensure that all care staff receive the appropriate training to do their jobs. EVIDENCE: The staff rota was seen and on the day and staffing was adequate to meet the number and needs of the service users resident. There were five care staff on duty during the waking day and two waking night staff due to be on duty. Staffing levels will need to be increased when additional service users are accommodated up to the maximum registered number of twenty-six. Designated care staff cover ancillary and laundry tasks and also prepare all the meals during the weekend. A cook works Monday to Friday and designated staff cover the cooking at the weekend. A new laundry assistant has been appointed. The Administration and Policies Manager stated that one care staff is working towards NVQ Level 4, three hold NVQ Level 3, and one NVQ Level 2 in care. Three staff are in the process of working towards Level 2. This was not evidenced at this time. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 22 Recruitment files were viewed during a separate visit made to the home on 22 September 2005. Not all staff files viewed demonstrated that robust recruitment procedures were followed with two appropriate written references, a satisfactory POVA check and Criminal Records Check (CRB) being received, prior to new staff commencing work in the home. During one monitoring visit the induction of new staff was discussed. One new member of care staff had not completed an induction as has had recently moved from another home where the induction had been completed. All new staff to the home should be fully inducted to ensure that they are aware of Brook Hill’s policies and procedures. The Administration and Policies Manager stated that induction training to meet the requirements has now been introduced and all care staff are completing this. Staff also confirmed this and it was not possible to evidence but progress will be reviewed again at the next inspection. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 23 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 and 38. The home does not have a plan in place to regularly review aspects of its performance through a good programme of self-review and consultations, to ensure that service users receive consistent quality care. Regular supervision of care staff is in place to ensure staff are supported to be able to perform their roles effectively. Satisfactory arrangements need to be put in place to ensure the health, safety and welfare of service users and staff. EVIDENCE: There has been a significant period of change in the home with the Registered Manager leaving in October 2004 and the Acting Manager in July 2005. Currently interim management arrangements are in place of with an Administration and Policies Manager (Acting Manager) and Deputy Manager Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 24 working in the home with support being provided by a former Registered Manager working for the Residential Recovery Service. The CSCI is awaiting an application to register a manager for the home, and the proprietors have stated that they are still working to address this issue. Currently there is not a quality assurance system in place to meet requirements of Standard 33. But staff stated that feedback about the service provided was being sought from service users relatives/representatives and is mentioned in the new newsletter compiled and subsequently sent out. Staff do not handle service users money. Where service users have spent money during the month a quarterly invoice is produced. Recording to support this activity, was viewed and was adequate. One individual supervision period for all care staff has been completed and recorded. The Administration and Policies Manager stated that a second is in the process of being booked with staff. There are also opportunities for staff to meet as a staff group. Standard 37 was not fully inspected but a regular recorded visit by a proprietor of the home to meet Regulation 26 has now commenced. To fully meet Standard 38 the following will need to be evidenced as being in place: a) Moving and handling training had been facilitated for staff to attend but with new staff joining the staff team at different times during the year a system will need to be in place for staff to access this training to meet induction standards. It was not clear that where moving and handling issues are identified who would complete the moving and handling assessment and provide guidance for staff to follow. b) The Deputy Manager advised the Inspectors during the monitoring visit on 8 September that an audit and staff training list was being completed of what training staff had completed and required. A list was also produced of training which had been booked. It was not clear on the day of the inspection if all staff had received training as required in first aid, basic food hygiene and moving and handling. Advice also needs to be sought to ensure that staff hold the required level of first aid training in sufficient numbers to provide adequate cover in the home. c) A written statement of the policy, organisation and arrangements for maintaining safe working practices has been put in place. A system is in place to record any incidents and accidents in the home and it was recommended that the storage of these facilitates easy access and the ability to identify any trends specific to individual service users. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 25 d) The Acting Manager has previously confirmed that the water system has been subject to chlorination but to fully meet requirements a recorded risk management assessment in relation to Legionella will need to be in place. It was understood that this is currently being drawn up. Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 26 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 1 3 1 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 X 3 2 1 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 x 3 3 X 1 Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 27 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 (1) a-c Requirement Timescale for action 30/11/05 2 OP3 3 OP4 4 OP7 5 OP7 That the Statement of Purpose has all the required detail within. This is an outstanding issue since 30.09.04 and 30.05.05. 14 (1) (a- That the pre admission d) assessment is more detailed to meet the requirements of the standard and is fully recorded. This issue is outstanding since 31.7.05. 18 (1) ( c) That confirmation is received (i) that staff have received training/guidance in providing care to service users with dementia. 15 (1) That service plans in place are subject to further development, to ensure that there are clear instructions for staff to follow in relation to individual service users assessed care needs, reflect leisure interests, likes and dislikes, and indicate long term goals. These are updated monthly and subject to review. This is an outstanding issue since 31.03.05 and 30.06.05 13 (4) (a) That the recording of risk (b) (c) assessments is further DS0000046374.V249594.R01.S.doc 30/11/05 30/11/05 30/11/05 30/11/05 Brook Hill Rest Home Version 5.0 Page 28 6 OP15 17 (2) Sch 4 (14) 18 (1) 7 OP18 8 OP19 13 (4) 9 10 OP19 OP24 13 (4) 16 (2) 11 OP25 13 (4) c) 12 OP25 13 (4) c) 13 OP25 16 (2) developed to give clear guidance to staff as to how the risks are to be managed. This is an outstanding issue since 31.03.05 and 30.06.05. That a record of meals provided to individual service users is maintained. This is outstanding since 31.07.05. (a) That confirmation is received that staff have received training/guidance for the Protection of Vulnerable Adults. (a) That the recording of routine fire checks carried out in the home evidence all the checks that had been completed. (a) That a maintenance plan for the home is put in place. (c ) That service users bedrooms be provided with furnishings to meet minimum requirements. If furnishings are not provided due to health and safety issues specific to individual service users then a risk assessment should be undertaken, recorded and available to view. Written confirmation is sent to the CSCI to confirm when these are in place. This is outstanding since 30.09.05. (a- That hot water is delivered to outlets accessed by service users near to the recommended safe temperature of 43 C. The CSCI receives confirmation as to how this has been addressed. This is outstanding since 17.05.05. (a- That evidence is supplied in relation to adherence to the Water Regulations 1999. This is outstanding since 31.07.05. (e) That a system is in place and maintained to ensure that all service users have their own DS0000046374.V249594.R01.S.doc 30/11/05 31/12/05 30/11/05 31/01/06 31/01/06 12/10/05 31/01/06 30/11/05 Brook Hill Rest Home Version 5.0 Page 29 14 OP29 19 (1) (b) (i) 15 OP33 24 (1) (2) (3) 16 OP38 13 (4) (a) 17 OP38 13 (5) 18 OP38 13 (4) (a) (b) (c) 19 OP38 12 (1) (a) clothes returned following laundering. That a system is in place to ensure that new staff have two written references in place and a POVA and CRB check prior to working in the home. This is outstanding since 30.06.05. That the quality assurance systems in place are further developed, to include an annual plan, continuous self monitoring, the results of service user surveys are made available to service users, and feedback sought from other stakeholders. This is an outstanding issue since 31.05.05. 30.09.05. That a risk assessment is undertaken and recorded within the home to minimise the risk of Legionella. This issue is outstanding since 31.07.05 and 30.09.05. That the CSCI receives confirmation of how moving and handling risk assessments will be completed where issues are highlighted. That the CSCI receives confirmation that advice has been sought and how first aid requirements have been met in the home. That evidence is provided that staff have received training in first aid, infection control and basic food hygiene. This issue is outstanding since 30.09.04, 30.05.05 and 30.09.05. 30/11/05 31/01/06 30/11/05 31/12/05 31/12/05 30/11/05 Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brook Hill Rest Home DS0000046374.V249594.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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