Inspection on 30/01/07 for Rivendale Lodge EMI Care Home

This inspection was carried out on 30th January 2007.

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 11/05/06

Rivendale Lodge EMI Care Home 12/10/05

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 EMI Care Home Brook Hill Rest Home 14 Prideaux Road Eastbourne East Sussex BN21 2NB Lead Inspector Judy Gossedge Key Unannounced Inspection 30th January 2007 09:00 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 EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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 EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook Hill EMI Care Home Address Brook Hill Rest Home 14 Prideaux Road Eastbourne East Sussex BN21 2NB 01323 731575 01323 738970 Brookhillch@aol.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 Sunjay Kumar Rai Mr Ashish Sharma Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number of places Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. 11 May 2006 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, with a lounge/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 to the first floor if required. All the bedrooms have a wash-hand-basin. The majority of bedrooms do not have ensuite 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 with a decking area at the rear of the home. The Statement of Purpose, Service Users Guide and a copy of the last inspection report are available to reference in the entrance to the home. At the time of the inspection fees were documented to be between £366.00 and £500.00. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours on 30 January 2007. There were two Inspectors present during the inspection. This is the second inspection carried out and not all the standards were inspected on this occasion. 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-three service users were resident, but due to communication difficulties it was not possible to speak to all service users individually, though a number were spoken to as part of the inspection process. The care that five of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal area. Fifteen service user surveys were sent out and five came back completed by the service users relatives. Four care staff; a general assistant, a domestic assistant, the activities co-ordinator, the admin and recruitment officer, the deputy manager and the Acting Manager were all spoken with. Five staff questionnaires were sent out prior to the inspection and no completed questionnaires were returned. Ten relative surveys were sent out and five came back completed. A District and student nurse who was visiting patients in the home was also spoken with. Following the last inspection on the 11 May 2006 the recruitment process followed in the home was found to be poor. As a result the CSCI issued a Statutory Requirement Notice, which required that nobody is deployed in the home without a POVA First check and that where a Criminal Records Bureau check (CRB) is awaited staff are closely supervised as required. A further visit was made to the home on 15 August 2006 when it was evidenced that the notice had been complied with. Currently there is still not a Registered Manager for the home and interim management arrangements are in place, with the Administration and Policies Manager in the position of Acting Manager. The Acting Manager stated that an application to the CSCI for a Registered Manager for the home has been made. The Residential Recovery Service, a consultancy service is also still providing support to the home. From 3 February 2007 the name of the home will change from Brook Hill to Rivendale Lodge. What the service does well: Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 6 The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. The care and support provided was observed and detailed in service users individual care plans to enable service users where possible to exercise choice whilst at Brook Hill. The majority of service users surveys stated they always receive the care and support they needed. The feedback from all the service users and visitors was that they were happy with the overall care provided in the home. Comments included ‘always welcome access to my relative in the home’ and ‘all management and staff come over as caring professionals’. A detailed Statement of Purpose and Service User Guide is in place. Regular activities are being organised for service users during the week with opportunities for service users to socialise with their relatives/representatives at events arranged in the home. A periodic newsletter is sent out to inform every one of the forthcoming events in the home. What has improved since the last inspection? What they could do better: Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 7 Service users individual plans of care should be kept under review to ensure that all the care needs recorded are up-to-date and continue to be met. Where service users are on a reducing diet medical and dietetic guidance should be gained prior to a service user starting a diet, to ensure this is appropriate and any diet to takes into account each individual service users dietary needs. The Registered Providers visit the home and recorded their visit to meet the requirements of Regulation 26. But it should be ensured that a recorded visit occurs monthly. 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. The summary of this inspection report can be made available in other formats on request. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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 EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is detailed information available about Brook Hill, with service users/representatives being provided with adequate information about Brook Hill in advance of their admission to the home. The admissions process ensures each service user’s care needs can be met in the home and that staff is being provided with adequate information in advance of an admission. But the detail being recorded on the pre-admission paperwork should continue to be developed. EVIDENCE: The Statement of Purpose, Service User’s Guide and a copy of the last inspection report are available to read in the entrance to the home. The majority of service user’s surveys stated they had received enough information about the home before moving in. One comment received was, ‘I was presented with the home’s regular news-sheets explaining what they do’. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 10 New service users are visited prior to any admission. This is to ensure individual service user’s care needs can be met in the home and to provide staff with information on the care to be provided. For two of the new service user’s resident their pre-admission information was viewed which had been completed. There is a detailed pre-admission format to be completed and the assessment process would benefit from this being more fully completed. New carers have an induction and attend mandatory training. There are policies and procedures in place for staff to reference. There is a programme for National Vocational Training (NVQ). All care staff has now received guidance/training for providing care to service users with dementia. Intermediate care is not provided in the home. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are protected by an individual detailed plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care which needs to be provided. But these need to be regularly reviewed to ensure that the information is up-to-date and details service user’s current care needs. There are medication policies and procedures in place. Service users are treated with respect. EVIDENCE: A selection of the service user’s individual care plans was viewed. The information detailed on the care plans continues to demonstrate that more detail is being recorded. This gives clear guidance to staff of the care to be provided, service user’s health care requirements, dietary needs, social and leisure interests, how any identified risks are to be managed. But the care plans had not been reviewed since October 2006 to ensure that this information is up-to-date and current care needs are being met. For example Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 12 where service users were recorded to be on a reducing diet there was limited supporting documentation and staff stated this was not still applicable for all service users as detailed in their individual plan of care (See standard 15). Service users religion is now recorded to ensure where a death occurs appropriate actions are taken in line with service user’s or relative’s wishes. The staff team were observed during the inspection to ensure that the privacy and dignity of service users is respected at all times. The care and support provided was observed and detailed in service users individual care plans to enable service users where possible to exercise choice whilst at Brook Hill. The majority of service users surveys stated they always receive the care and support they needed. The feedback from all the service users and visitors was that they were happy with the overall care provided in the home. Comments included ‘always welcome access to my relative in the home’ and ‘all management and staff come over as caring professionals’. Medication policies and procedures are in place and the administration of medication was observed at lunchtime. Staff administering medication has received medication training. The storage and a sample of the recording of the administration of medication were also viewed and were adequate. But however where any verbal instructions are received from a medical professional to change a service users medication this should be clearly recorded. This was discussed with the Acting Manager who stated this would be addressed. Where completed all the service user surveys indicated that service users felt that their medical care needs were met in the home. Feedback from visiting medical professionals stated that they were happy with the overall care provided. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have regular opportunities to participate in a range of social and recreational activities provided. A varied diet is provided, which offers a choice at every meal, but where special diets are provided medical and dietary guidance and support should be sought. EVIDENCE: Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 14 Service users social interests are recorded on their individual care plans and a regular programme of activities has been arranged. An activities’ co-ordinator works in the home twenty hours a week over five days, who organises the activities’ and additionally care staff may facilitate an activity after the coordinator had finished for the day. External entertainment/activities groups are also arranged to provide entertainment in to the home, which includes a weekly exercise group for service users. The service user surveys completed indicated a mixed response with service users stating activities were always or usually organised in the home. Records were also viewed of activities, which had been facilitated. On the day of the inspection a small group of service users were playing bingo and there was a pleasant atmosphere and good interaction between staff and service users was observed. The lounge is decorated and personalised with some of the themed artwork service users have completed in preparation for Valentines Day and the activities coordinator spoke of plans for activities with an Easter theme. A periodic newsletter is sent out to inform every one of the forthcoming events in the home. One relative commented, ‘so far after only a few weeks we attended a supper/firework display laid on by the management and the staff. Excellent job well done’. A new rotating menu is to be implemented from next week, which the deputy manager stated has been seasonally varied, takes into account service users likes and dislikes and was seen to identify the choices available at all meals. Special diets are catered for. Records viewed evidenced that all the service users have recently been placed on a reducing diet and service users individual weight charts recorded significant weight losses for some service users. Medical and dietetic guidance and support had not been gained for each individual service user prior to the service users starting the diet, to ensure an appropriate diet to take into account each individual service users dietary needs are met. The outcome of any guidance should be recorded. Lunch on the day was sausage casserole, potatoes, broccoli, peas and cauliflower, or scampi, chips, mushroom, tomatoes and salad followed by chocolate pudding and sauce or apples and ice cream. The deputy manager stated that there is a regular order of fresh fruit delivered to the home for the service users. Some service users observed were being assisted with their meal in the dining room and lounge area and it was a relaxed environment taking into account the different length of time that individual service users. It was possible to evidence a varied diet for all service users from the records kept of food consumed individually by each service user. The service user surveys completed indicated a varied response of always, usually or sometimes enjoying the meals provided. Comments received were ‘my relative enjoys them’ and ‘my relative never refuses food’. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: There is a detailed complaints policy and procedure in place. The Acting Manager stated that no complaints had been received at the home since the last inspection. The CSCI have not received any concerns in relation to the care provided at Brook Hill. The service user surveys stated that they know how to make a complaint and who to speak to if they are not happy. The relatives surveys that one relative had raised a concern but that they were happy with the way that this had been dealt with. There are policies and procedures in place in relation to the protection of vulnerable adults and training records evidenced staff had attended related training. One care assistant spoken with confirmed they had attended this training and demonstrated an awareness of the policies and procedures. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment continues to be improved to ensure that service users are provided with a safe, attractive, clean and homely place to live. EVIDENCE: Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 17 The external décor of the home has been improved with the installation of new windows and external doors. There are still some windows to be replaced and the Acting Manager stated that this work is ongoing and it is planned to finish this work by April 2007. There is a garden to the rear of the home, which now has a decking area. Access to the garden is via a doorway off the lounge where there is a steep ramp in place. This was discussed with the Acting Manager who stated that the staff team follows the risk assessment in place when assisting service users outside using the ramp. There is not a passenger lift in the home, but the Acting Manager stated that the proprietors are currently seeking planning permission for a passenger lift to be installed to access all floors in the home. A stair lift is available to service users unable to use the stairs to the first floor. Access to the second floor is by way of a steep stairway with no alternative means of escape in case of a fire. Stair gates have been fitted on this stairway. The Acting Manager stated have a risk assessment has been completed and the fitting of these discussed with representatives from the external fire company who recently completed a fire risk assessment for the home and were satisfactory. 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 continue to be reviewed on a regular basis to ensure their safety and care needs continue to be met whilst resident on the second floor. 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. The décor and furnishing of the bedrooms is variable and continues to be improved. A number of bedrooms displayed service users individual styles and interests. It was not always possible identify service user’s specific bedrooms due to a lack of identification on the bedroom doors, which it was understood would be rectified following the completion of redecoration works in the home. Nightlights have been purchased instead of a bedside light. Though some bedside lights have been provided if this is identified to meet individual service users care needs. Not all bedrooms had a rubbish bin, but following this issue being raised at the last inspection there are now bins provided in communal areas in the home to enable staff throw away their disposable aprons and gloves. An emergency call system was fitted in the home during 2005 so all bedrooms now have an emergency call bell system. A number also have an alarmed floor mat to alert staff particularly at night where a service user may need assistance. Service users are unable to control the temperature in their own bedrooms. The homes recording of the testing of the hot water temperatures was viewed and detailed that water at outlets accessed by service users is being maintained at close to 43 º C. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 18 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, particularly on the ground floor where most of the service users were observed to spend a significant part of their day. The proprietors have stated that they have reviewed this and currently there are no plans to increase the number of toilet facilities. But the main toilet used off the lounge area has been extended so that it is more easily accessible and was is in the process of being redecorated. This does mean that as well as the door at the entrance to the toilet there is also an external fire door and exit leading out to the back of the home. This was discussed with the Acting Manager who stated that advice and guidance again had been sought from a representative from an external fire company as part of the fire risk assessment for the home and that this was acceptable. There is one lounge/dining area on the ground floor and is where the majority of the service users congregate during the day. At the time of the inspection this was in the process of being redecorated following the loss of two walls from an adjacent staff room, which has been incorporated into and extended the communal space available. The Acting Manager stated that when the redecoration has been completed new flooring will be laid and new dining room furniture is being sought. Where the walls have been removed the flooring is uneven and prior to the new flooring being laid the Acting Manager has put down temporary floor covering to help ensure the safety of service users. This was discussed with the Acting Manager to keep this under review to ensure these precautions remain adequate. The floor finish in the laundry is readily cleanable. A system is in place to sort clothes in the laundry area and ensure all items of clothing are named. The home was clean and odour free in the majority of the home although there were a couple of bedrooms where there was a slight odour. The service user surveys stated service users felt the home was always or usually fresh and clean. One comment received was, ‘no unpleasant odours at all’. The domestic staff member working on the day was spoken with and had not received training/guidance in infection control, control of substances hazardous to health regulations (COSHH). The Acting Manager stated that in-house guidance had been given on COSHH, but that it was planned for formal training to be provided shortly, so a requirement has not been made Recording of routine fire checks carried out in the home were viewed and were adequate. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing was adequate on the day to meet the care needs of the service users resident and a robust recruitment procedure was demonstrated to be in place to ensure service users are in safe hands at all times. Care workers are being provided with training to ensure they can meet the care needs of the service users. EVIDENCE: Staffing on the day was adequate to meet the number and care needs of the service users resident. There is still a reliance on agency staff to work in the home at night, but there are further care staff currently being recruited to work in the home to address this. Staffing levels will need to continue to be reviewed when additional service users are accommodated up to the maximum registered number of twenty-six. There are ancillary staff that work in the home, cover catering, domestic and laundry tasks. On the day the cook was absent and the deputy manager was cooking the meal. The majority of relative’s surveys stated that they felt there were adequate numbers of staff on duty during their visits. Service users surveys completed indicated that majority of service users felt that they received the care and support that they needed, that staff listened and acted upon what was said to them and that staff were always available when they were needed. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 20 Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care by April 2005. But the Acting Manager confirmed that one care assistant holds an NVQ Level 2 in care, eight care staff are currently working towards NVQ level 2 in care and three towards NVQ level 3. The recruitment process followed was viewed for five new members of staff working or due to commence working in the home and which evidenced a satisfactory recruitment practice in place. The Acting Manager was able to confirm that all staff have completed a CRB/and or a Pova First check anfd stated that no member of staff now work in the home prior to the receipt of a satisfactory POVA First check. The Acting Manager has stated that induction training to meet the requirements has now been received and will be introduced for the new staff working in the home to complete. One new member of care staff spoken with confirmed they are about to start their induction. The Acting Manager stated that the home had recently been awarded the YMCA training award, ‘Super Employer Award’ for 2006 in recognition of its training achievements. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is still not a Registered Manager for the home, but an application has commenced with the CSCI to address this. A quality assurance plan is in place to give the proprietors and staff feedback on the service provided. Regular supervision of care staff has been introduced and maintained to ensure the staff is supported to be able to perform their roles effectively. Systems are in place and maintained to ensure a safe environment for staff and service users. EVIDENCE: Interim management arrangements are in place, with the Administration and Policies Manager working as the Acting Manager for the home. He has completed the Registered Managers Award and is about to commence NVQ Level 4 in Care. There have also been further training opportunities which the Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 22 Acting Manager has attended. There is a deputy manager and support is provided from the Residential Recovery Service, a consultancy service. The Acting Manager stated that an application to register a manager for the home has now commenced. A quality assurance system has been developed. It was evidenced that feedback about the service provided is being sought from service users, relatives/representatives and other professionals who attend the home, all of which has been collated and the Acting manager stated that all service users representatives had received a copy. The overview detailed that there had been a seventy-five percent response to the questionnaires distributed during the survey period. When asked about the general satisfaction of the care provided the majority of responses stated very good and good. A regular recorded visit by a proprietor of the home to meet Regulation 26 has been recorded but it needs to be ensured that these occur monthly. Supervision for all care staff has been introduced and maintained to meet the requirements of Standard 36. Staff spoken with confirmed good access to training and of attendance on health and safety training. There are detailed training records so it was possible to evidence if all staff had received training in moving and handling, basic food hygiene, first aid and infection control within the required timescales and there are further training updates planned over the next two months. The Acting Manager stated that he and the deputy manager are due to attend a moving and handling risk assessors course so that they can complete any moving and handling risk assessments where identified in the home. The proprietor has recently commissioned an external agency to complete a fire risk assessment for the home and stated that the recommendations made following this have been addressed. Records evidenced that staff attended fire training and there are also fire drills facilitated in the home. Although the Acting Manager stated that there was a regular a regular environmental check of the building there was no record of this and this includes a fire check. The Acting Manager stated that this would be incorporated in to the existing checks but would also be recorded, so a requirement has not been made on this occasion. An external provider was commissioned last year by the proprietors to undertake an environmental risk assessment of the building. It was possible to evidence that a programme to review this has been introduced. A recorded risk management assessment in relation to Legionella is now in place and monitoring systems were in place in relation to the prevention of Legionella. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 23 Records viewed evidenced the maintenance of equipment and services has been carried out. Recording was viewed of incidents and accidents, which had occurred in the home. There was no collation of this information to view, which would help to facilitate easy access and to identify any patterns in incidents and accidents, which have occurred in the home. Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 3 Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes Brook Hill EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 26 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. 2. Standard OP7 OP15 Regulation 15 (2) (b) 16 (2) (i) Requirement Timescale for action 28/02/07 3. OP33 26 (3) (4) (a-c) (5) (a) That the service users individual plan of care is kept under regular review. That medical and dietetic 28/02/07 guidance is gained prior to a service user starting a diet, to ensure an appropriate diet to take into account each individual service users dietary needs are met. That the Registered Provider will 28/02/07 undertake a monthly visit to the home, which will be recorded, and a copy is sent to the CSCI. This issue is outstanding since 30/06/06 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 EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 EMI Care Home DS0000046374.V326720.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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