Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 17/05/05 for Rivendale Lodge EMI Care Home

Also see our care home review for Rivendale Lodge EMI Care Home for more information

This inspection was carried out on 17th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home presents a relaxed atmosphere. It was clean and there were no offensive odours.

What has improved since the last inspection?

Since the last Inspection a Statement of Purpose has been written but this needs to be reviewed as all the detail required is not in place. A new call system in the home has been ordered and subsequently fitted. There has been some upgrading of equipment in the laundry and kitchen areas. Additional hand washing facilities have been provided, and an external company is in the process of completing risk assessments to ensure safe working practices in the home. A written fire risk assessment is in place, and staff have received fire training. Staffing has been increased in the evening following concerns raised.

What the care home could do better:

A Service Users Guide is not in place or the availability of the inspection reports for reference. Assessments for new service users do not contain the required detail to ensure that new service users care needs can be met. Individual service plans and supporting risk assessments are still inadequate and do not provide staff with sufficient guidance to ensure that their care needs are being met. A maintenance programme for the home is not in place and furnishings in the service users bedrooms do not meet minimum requirements. There has been a period of instability with a number of staff leaving the home and new staff being recruited. Sample documentation viewed did not evidence that robust recruitment procedures were in place to protect the service users. Induction training has not been reviewed or foundation training in place to meet the National Training Organisation (NTO) requirements. Regular visits by the providers which are recorded to meet the requirements of Regulation 26 visits need to be maintained. Care staff are not receiving supervision, have had training to provide care to service users with dementia, or received all the required health and safety training.

CARE HOMES FOR OLDER PEOPLE Brook Hill Rest Home 14 Prideaux Road Eastbourne East Sussex BN21 2NB Lead Inspector Judy Gossedge Unannounced 17 May 2005 09:10 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 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 H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Brook Hill Rest Home Address 14 Prideaux Road Eastbourne East Sussex BN21 2NB 01323 731575 Telephone number Fax number Email 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 (DE(E)) 26 registration, with number of places Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. That all service users to be accommodated are sixty five years or over on admission. 2. That service users admitted have a dementia type illness. 3. That no more than twenty six (26) service users are accommodated at any one time. 4. That second floor accommodation is restricted to use by service users who are ambulant and can access their private accommodation independently. Date of last inspection 19 January 2005 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 eleven 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 not a passenger lift, but there is equipment provided in the home to help service users up and down the stairs if required. There are no ensuite facilities but 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 H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours on 17 May 2005. This is the first statutory inspection of this year. Currently the home is being managed by an Acting Manager. The CSCI has received anonymous formal complaints since the last inspection 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, and are still ongoing. Three monitoring visits have also been carried out on 8, 12 and 17 April 2005 to review compliance with requirements made following the last inspection and as part of complaints investigation. During these visits three serious concerns were identified. These issues are detailed in the report under the relevant standard with details of the requirements made. The CSCI have also met with the proprietors for the home to discuss outstanding requirements and work in progress to meet ongoing requirements. Where these have not been completed or will not be met new timescales have been set in the report. A tour of the premises took place to look at communal areas and a selection of service users bedrooms, rotas and care records were inspected. Twenty-one service users were resident, but due to communication difficulties it was not possible to speech 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. Six care staff, the cook on duty and the Acting Manager were spoken to. Two relatives regular visitors to the home were also spoken with and four visiting District Nursing staff. What the service does well: What has improved since the last inspection? Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 6 Since the last Inspection a Statement of Purpose has been written but this needs to be reviewed as all the detail required is not in place. A new call system in the home has been ordered and subsequently fitted. There has been some upgrading of equipment in the laundry and kitchen areas. Additional hand washing facilities have been provided, and an external company is in the process of completing risk assessments to ensure safe working practices in the home. A written fire risk assessment is in place, and staff have received fire training. Staffing has been increased in the evening following concerns raised. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 8 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 standard(s) 1, 3, 4 and 6. There is not sufficient information available to be viewed prior to any admission to the home. Pre-admission procedures in place do not provide enough detailed information to ensure that service users admitted are appropriately placed, or to assist in the completion of the individual service plan. Care staff have not received the required training in providing care to service users with dementia to ensure that they have the knowledge to provide this care. EVIDENCE: A Statement of Purpose is now available to view, but does not detail all the required information. A Service Users Guide with regular quality assurance information collated for service users and their carers to read, and previous inspection reports to reference is not in place. One comment card received from a carer/visitor following the last announced inspection stated that they had not had access to the inspection reports in the home. This was raised again with the Acting Manager who confirmed the reports are still not accessible for reference in the home. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 9 New service users are visited prior to admission to ensure individual service users needs can be met in the home and to provide staff with information on the care to be provided. There were two new service users resident and the pre-admission information had been completed, but both were limited in detail, and did not provide staff with the appropriate information. Not all staff have received training for providing care to service users with dementia. Intermediate or rehabilitative care is not provided. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 10 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 standard(s) 7, 8, 9 and 11. The individual care plans do not adequately provide staff with the information they need to ensure that service users are receiving the care and support necessary to meet their individual health and personal care needs. The medication policies and procedures in place do not protect the health, safety and welfare of the service users. Policies and procedures in relation to death and dying need to be reviewed and staff made aware of these to ensure that when providing this care, service users care needs continue to be met. EVIDENCE: Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 11 A selection of service users individual care plans were viewed. The information detailed on care plans did not 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. These should then be updated monthly and subject to regular review to ensure any changes in service users care needs are met. One service user had fallen the previous week and had a fractured arm. There was no care plan in place, guidance on after care from the hospital had not been received or subsequently requested. The regular recording of service users weights is not adequate. During the monitoring visit on 8 April 2005 it was found that one new service user admitted to the home on 4 April 2005 did not have a care plan. A serious concern was detailed in separate correspondence following the issue of an Immediate Requirement form for this to be rectified by 11 April 2005. A further visit on 12 April 2005 did not demonstrate that a care plan had been put in place. This was subsequently resolved. Medication is administered from a trolley which was seen to be left for periods in the lounge unattended. This health and safety issue was raised on the day with the Acting Manager. The morning medication due at breakfast time was not administered until 11.30 am with the after lunch medication due to be administered at 1.30 pm. The member of staff administering the medication was seen to be using covert methods in some instances of administration. An Immediate Requirement was left detailing that further guidance and support is sought and recorded to support this activity. Subsequently a visit to the home has been made by a CSCI pharmacist who has inspected the policies and procedures in place. Where issues require addressing these have been detailed in separate correspondence and a written response required to confirm action taken. A monitoring visit was made on 12 June 2005 during evening. One service user was very poorly, and two District Nurses called to the home to provide care during the monitoring visit. Two care staff were on duty during the night. The Inspectors spoke to the duty on call manager for the home regarding the insufficient number of staff on duty to provide care to the twenty-one service users resident with this one service user who needed additional care and support during the night. The duty manger confirmed that a further member of staff would be provided to provide one to one support for this service user. Policies and procedures on death and dying in the home should be reviewed to ensure that the individual service plans are kept updated to ensure that care needs continue to be met in the home, and that staffing levels are kept under review to ensure that adequate staff are on duty to meet the care needs of all the service users resident. A Social Services Assessor spoken with following the monitoring visit and records of feedback received confirmed that social and health care Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 12 professionals visiting the home were happy with the quality of the care being provided by the staff to this service user. . Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 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 standard(s) 12 and 15. Service users have limited opportunities to participate in activities in the home so their social care needs are not being met. The meals in the home are good offering variety, but limited choice and caters for any special dietary needs. Records of meals provided to service users need to be maintained and monitored to ensure that individual service users nutritional needs are being met. EVIDENCE: An aroma-therapist was at the home during the morning to give service users a hand massage. A musician was due to play during the afternoon. The Acting Manager stated this was not the norm, that a regular programme of activities is not in place and limited activities are provided. A new member of staff has been recruited to facilitate activities during the week. The lunch of liver casserole was appetising and well presented. But there was no alternative offered Four service users did not like the liver casserole and would not eat it. The Inspectors informed the Acting Manager and cook requesting that an alternative was provided. There is limited choice from the main meal provided, and the Inspectors were informed that most service users eat the main meal provided. There are no Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 14 records of service users dietary likes and dislikes, and these need to be considered through the admission process and reviews of the individual service plans. It was understood that a new menu was being planned with increased choice at breakfast including the option of a cooked breakfast, and that an alternative to the main meal be available. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 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 standard(s) 16 and 18. There is a clear and effective complaints procedure in place. Agreed Adult Protection policies and procedures need to be followed to ensure the health, safety and welfare of the service users. EVIDENCE: There is a detailed complaints policy and procedure in place, which the Acting Manager has updated. The record of complaints was viewed with one formal complaint having been received which had been investigated. The monitoring visit on 8 April 2005 highlighted a complaint which had been investigated by staff in the home. This should have been referred to ESCC Social Services to be considered within Multi Agency Adult Protection Procedures, and the CSCI informed. A serious concern was raised with the proprietor in separate correspondence with the requirement that the proprietors and staff are fully aware of the East Sussex, Brighton and Hove Multi-Agency Procedures for the Protection of Vulnerable Adults, and that the homes adult protection policies and procedures are reviewed to ensure adherence to multi-agency procedures. The CSCI has received written confirmation that this has been addressed. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 16 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 standard(s) 19, 21, 22 ,23, 24, 25 and 26. The standard of the environment varies and a maintenance programme needs to be put in place to ensure the environment is maintained and provides service users with a safe, attractive and homely place to live. The home is clean and free from odours. EVIDENCE: 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. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 17 In general the bedrooms are well decorated, and some displayed service users individual styles and interests. Bedrooms are not furnished to meet minimum standards, and 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. Not all bedrooms have a call bell system the proprietors have subsequently confirmed that a new emergency call system is in the process of being installed in the home. There are bathroom facilities 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. Service users are unable to control the temperature in their own bedrooms. At the last inspection one service users bedroom felt cold and the service user commented their bedroom was cold. This was reported to the Acting Manager for an immediate resolution. Further feedback received from staff and service users, is that some of the bedrooms can still be cold. The proprietors have subsequently confirmed that supplementary heating will be provided whilst further work is completed on the main heating system to resolve this issue. Where supplementary heating is provided risk assessments will need to be completed, recorded and available to view. A sample of wash hand basins and baths used by service users were tested and where one was much lower than the recommended safe temperature, this was reported to the Acting Manager and an Immediate Requirement form was issued. 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 still considering options to enable one to be fitted. Currently a stair walker is available in the home. It is required that when in use a risk assessment is undertaken and recorded to ensure individual service users safety. There is one lounge and dining area on the ground floor. Some of these areas are starting to show some evidence of wear and tear. This has subsequently been discussed with the proprietors and a maintenance plan for the home will need to be put in place. The floor finish in the laundry is not readily cleanable. The home was clean and odour free at the time of the inspection. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 18 Recording of routine fire checks carried out in the home were viewed and were adequate. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. There has been a period of considerable instability in staffing in the home. Staffing levels are not sufficient to ensure that service users needs are always appropriately met. Robust recruitment policies and procedures need to be in place and followed in order to protect service users. Induction and foundation training to meet requirements should be in place to ensure that new staff receive the appropriate training to do their jobs. EVIDENCE: The staff rota was seen. The Acting Manager’s hours worked in the home were not recorded and should be. The number of care staff on duty did not match the number to be on duty as recorded on the rota, and the Acting Manager stated this was due to staff sickness on the day. Designated care staff also cover ancillary and laundry tasks and also prepare all the meals during the weekend. The Inspectors have subsequently been informed that additional staff will be recruited to cover ancillary tasks in the home, and an agency cook has been working at the weekend while this post is being recruited to. The Acting Manager confirmed that there have problems in recruiting new staff to work in the home. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 20 During the monitoring visit on 12 April 2005 concerns over the staffing levels were raised. This is detailed under Standard 11 in the report. Additionally concerns were raised at the staffing provided earlier in the evening when the day staff finish their shift and the night staff commence. From 8.00 pm only two care staff were on duty, covering some ancillary tasks and providing care to twenty-one service users on all three floors of the home. Ten service users were still up when the Inspectors left the home at 9.45 pm. For the majority of the time these service users were left unsupervised in the lounge area, and it was obvious that a number required some assistance from staff. One service user requires the assistance of two members of staff each time care is given. Records viewed of incidents and accidents in the home evidenced a very high level of falls between 8.00 pm and 11.30 pm. A serious concern was raised and requirement made detailed in separate correspondence that staffing levels at this time should be reviewed to ensure adequate staff were on duty. The proprietors have since confirmed that an additional member of staff will now be on duty until 10.00 pm, and that staffing levels early in the morning will also be increased. The staffing levels detailed in the Statement of Purpose needs to be reviewed as this does not reflect the staffing as detailed on the rota viewed and is not in line with recent requirements. Staffing levels should be kept under regular review to ensure that the needs of the service users continue to be met. Recruitment files were viewed. Not all 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. Induction and foundation training is not in place to meet the NTO requirements. The Acting Manager stated again that options are currently being reviewed to address this standard. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 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. Regular supervision of care staff needs to be in place to ensure staff are 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: The home has gone through a period of change with the Registered Manager leaving in October 2004 and the home currently being managed by an Acting Manager, who has resigned and is due to leave in July 2005. The CSCI is Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 22 awaiting an application to register a manager for the home, and the proprietors have stated that they are working to address this issue. The Acting Manager confirmed that currently there is not a quality assurance system in place to meet requirements. But feedback about the service provided was being sought from service users visitors/carers. Standard 37 was not fully inspected but a regular recorded visit by a proprietor of the home to meet Regulation 26 is not being maintained. The Acting Manager stated that supervision for care staff which had been introduced in to the home is currently not being maintained. To fully meet Standard 38 the following will need to be evidenced as being in place: Training is provided in first, basic food hygiene, and infection control is provided for staff to access. That the written statement of the policy, organisation and arrangements for maintaining safe working practices is further developed. 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. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x 2 2 3 2 2 2 STAFFING Standard No Score 27 1 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x 1 x x 1 x 2 Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 24 Yes Are there any outstanding requirements from the last inspection? 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) 5 (1) (a-f) Requirement Timescale for action 30.06.05 2. OP3 14 (1) (ad) 18 (1) (c) (i) 3. OP4 4. OP7 15 (1) That the Statement of Purpose is reviewed to ensure all the detail as required is detailed within. A Service Users Guide is developed and made available to service users and their carers. Also that the inspection reports are aslo available for reference. This is an outstanding issue since 30.09.04 and 30.05.05. That the pre admission 31.07.05 assessment is more detailed to meet the requirments of the standard and is fully recorded. That a programme is in place to 31.07.05 ensure that where appropriate staff have received training/guidance in providing care to service users with dementia. The timescale for this requirement has been extended from 31.05.05. That service plans in place are 30.06.05 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 Version 1.20 Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Page 25 5. OP7 13 (4) (a) (b) (c) 6. OP9 13 (2) 7. OP12 16 (1) (m) 8. OP15 9. 10. OP19 OP21 16 (2) (i) 17 (2) Schedule 4 (14) 13 (4) (a) 23 (2) (j) 11. OP24 16 (2) (c) monthly and subject to review. This is an outstanding issue since 31.03.05. That the recording of risk assessments is further developed to give clear guidance to staff as to how the risks are to be managed. This is an outstanding issue since 30.04.05. Written confirmation is sent to the CSCI to confirm when these are in place. That advice and guidance is sought in the adminisration of covert medication and this is recorded. That leisure and social activities are subject to review and further development. This is an outstanding issue since 30.04.05. That a choice is provided at meal times and a record of meals provided to individual service users is maintained. That a maintenance plan for the home is put in place. That a review of the toilet facilities available to service users on the ground floor and near to the dining and lounge areas is undertaken to assess the adequacy of toilets for the numbers of service users accommodated. This is an outstanding issue since 30.12.04, and 30.06.05. That service users bedrooms be provided with furnishings to meet 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 30.06.05 17.05.05 30.06.05 30.06.05 31.07.05 30.09.05 30.09.05 Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 26 place. 12. OP25 13 (4) (ac) That hot water is delivered to outltts accessed by service users near to the recommended safe temperature of 43 C. That evidence is supplied in relation to adherence to the Water Regulations 1999 That the floor finish in the laundry is readily cleanable. This is an outstanding issue since 30.12.04 and 30.06.05. 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. That staff complete induction and foundation training to meet NTO requirements. This is an outstanding issue since 31.05.05. 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. That care staff receive supervision to meet the requirements as detailed within the standard. This issue is outstanding since 31.05.05. That the registered provider will undertake a monthly visit to the home, which will be recorded, and a copy is sent to the CSCI. This issue is outstanding since 31.05.05. That a system is in place to ensure that the CSCI is made aware of significant events. 17.05.05 31.07.05 13. OP26 13 (3) 31.07.05 14. OP29 19 (1) (b) (i) 30.06.05 15. OP30 18 (1) (a) 30.06.05 16. OP33 24 (1) (2) (3) 30.09.05 17. OP36 18 (2) 30.06.05 18. OP36 26 (3) (4) (a-c) (5) (a) 30.06.05 19. OP36 37 (1) (ag) 30.06.05 Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 27 20. OP38 12 (1) (a) 21. OP38 13 (4) (a) 22. OP38 13 (4) (ac) That a programme is in place to 30.09.05 ensure where appropriate staff have received training in first aid, infection control and basic food hygiene. This issue is outstanding since 30.09.04, and 30.05.05. That a risk assessment is 31.07.05 undertaken and recorded within the home to minimise the risk of Legionella. This issue is outstanding since 31.03.05. That the written statement of the 30.06.05 policy, organisation and arrangements for maintaining safe working practices is further developed. This issue is outstanding since 31.03.05. 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. 3. 4. Refer to Standard OP9 OP11 OP21 Good Practice Recommendations That all verbal instructions from a GP are recorded, signed and dated. That the policies and procedures for death and dying are updtaed. That the current provision for bathing facilities is kept under review to ensure that all are accessible for service users to use, and continue to meet their needs. Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 28 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Brook Hill Rest Home H59-H10 S46374 Brook Hill V218003 170505 Stage 4.doc Version 1.20 Page 29 - 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!