Inspection on 08/06/06 for The Brooklands

This inspection was carried out on 8th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Brooklands 12/06/07

The Brooklands 25/05/05

The Brooklands 16/09/04

The Brooklands 27/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Brooklands (The) Coombs Road Bakewell Derbyshire DE4 1AQ Lead Inspector Anthony Barker Key Unannounced Inspection 8th June 2006 09:20 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 Brooklands (The) DS0000019949.V297811.R01.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. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands (The) Address Coombs Road Bakewell Derbyshire DE4 1AQ 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) (01629) 812023 (01629) 814105 Christian Homes for the Elderly Mrs Janice Barbara Hallam Care Home 19 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (9) of places Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To register one bed for DE(E) for the individual named in the notice of proposal for the duration of their stay. 20th September 2005 Date of last inspection Brief Description of the Service: Brooklands is a Christian Residential home and is run by a non-profit making organisation. It is in an older building, which has been adapted to residential home use, and is situated in its own grounds on the outskirts of Bakewell. It is registered to provide services for 19 people, including 10 for older people with dementia. A choice of lounges and dining rooms is provided. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8.5 hours in June 2006 and was a routine unannounced inspection. The last inspection took place in September 2005 and was unannounced. Four residents, the Manager and one member of staff were spoken to and records were inspected. There was also a tour of the premises. Three residents were case tracked so as to determine the quality of service from their perspective. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Medication recording practices must be improved – including the recording of Controlled Drugs in the proper Record Book. All information and documents, detailed in the Regulations, must be in place before staff are appointed. All staff who works night shifts must be provided with fire precaution training at least twice a year. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 6 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. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 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 the following standard(s): 3&6 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were admitted to the Home only on the basis of a full assessment of their needs. EVIDENCE: The files of the three case-tracked residents were examined. One of these residents was admitted within the previous four weeks. All files showed that residents were being admitted only after a full assessment of need regardless of whether they were self-funding or funded by Social Services. Intermediate care was not being provided by this Home. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 9 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): 7,8,9 & 10 Quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs were set out in individual care plans. Their health was being promoted although residents were not being fully protected by the Home’s medication procedures. Residents felt they were being treated with respect. EVIDENCE: The care plans of the three case-tracked residents were examined and were found to cover an appropriate range of topics. They were being reviewed at satisfactory intervals and this was being done, the Manager stated, in consultation with residents or their representative. However, this was not supported by a signature on the care plans. The Manager was recommended to review the wording on some plan sheets as not all set out the action needed to be taken by care staff, as outlined in Standard 7.2. The Home’s Contact Sheets provided a good ongoing record of staff members’ observations regarding individual residents’ physical and health needs and, taken together with individual Activity Sheets, gave a holistic view of how resident’s needs were being met. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 10 Risk assessments were in place to address residents’ falls and other topics such as wandering. They were being reviewed. From discussion with the Manager it was clear that other risks, such as the moving and handling of residents, were being addressed – although these were not always being recorded as risk assessments. Contact from a wide range of health professionals was being well recorded, including regular contact from district nursing services, when necessary. There were, currently, no residents in need of specialist equipment in order to promote tissue viability. Medication Administration Record (MAR) sheets included a photograph of each resident and their individual medical history. A sheet in front of the MAR sheets was being used to record the training of a care assistant who was administering medication under the supervision of a senior carer. This was good practice. However, some other areas of recording practices were unsatisfactory.... • there was no recorded quantity, date received or signature beside two antibiotics prescribed to one case-tracked resident, • a handwritten change of medication, on another case-tracked resident’s MAR sheet, had no associated signature or counter-signature, • a third resident had no start date on the current MAR sheet – therefore the actual month was not clearly recorded. Also, there was duplication of 5 of this resident’s 6 items of medication, on 31 May, on a separate MAR sheet. The Home held a Controlled Drug Record Book but this was blank and controlled drugs were being recorded on MAR sheets along with other prescribed medication. Controlled drugs were being stored safely. Household remedies were being stored in a locked cupboard along with a record of their usage. Two of the case-tracked residents stated that they felt they were being treated with respect by staff. One said, “They are very nice to me”. Staff were heard to talk respectfully to residents. One member of staff gave appropriate examples of how residents’ are treated with dignity and how their need for privacy is met. In conversation with the Manager it was clear she appropriately followed a code of confidentiality when discussing residents when others might overhear. Residents’ files included a Bereavement Form that indicated family details and funeral arrangements. Other aspects of standard 11 were not assessed on this occasion. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 11 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 & 15 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from flexible routines and activities that were stimulating. They maintained contact with family and friends and were helped to maintain choice and control over their lives. Residents were receiving a wholesome and balanced diet. EVIDENCE: One case-tracked resident reported that she was able to, “do what and when I want...late to rise and late to bed”. A member of care staff confirmed that residents’ preferences for getting up and going to bed times were recorded in care plans and were respected - none rose “much before 7am” she added. Separate sheets of individual residents’ activities were examined. These showed the visitors each resident saw and activities they were involved in – providing a good record of each individual’s social life. The pre-inspection questionnaire listed a good range of activities and a staff member confirmed this, adding that, “We have time to give one to one with residents”. Two casetracked residents confirmed particular activities they enjoy and one said of the activities, “I like the togetherness”. There was evidence in the dining room and lounge areas of craft and painting projects undertaken by residents. There were examples, too, of materials from reminiscence activities. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 12 The Residents’ Activities sheets and signing-in book showed that residents receive regular visitors and the Manager confirmed that the Home had an ‘open door policy’ with respect to visitors. Two case-tracked residents confirmed that they receive visits from family members and one added that she had church visitors, too. The Manager gave details, in the pre-inspection questionnaire, of 13 residents whose family members act as advocate for them. No residents were handling their own money and neither the Registered Provider or Manager acts as appointee for handling residents’ financial affairs. In the file of one casetracked resident was seen an extensive list of personal items he brought with him on admission, including ornaments and several items of furniture. These items were seen during a tour of the premises. Residents were positive about the food provided by the Home. One casetracked resident said it, “was nicely cooked” and that alternatives were always available. Lunch was observed during this inspection and it appeared and smelt appetising. Dining tables were attractively set. The Home’s 4-week rolling rota was examined and indicated that residents were provided with a varied and nutritious diet. The kitchen larder was very well stocked and home made cakes were seen. The Manager spoke of a buffet social evening planned for the coming Saturday – an event held every three months. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were confident that their complaints would be listened to, taken seriously and acted upon. They were being protected from abuse. EVIDENCE: The Home had a complaints procedure displayed in the hall. It was appropriately worded. The Home’s complaints record was examined. Four complaints had been recorded within the previous 12 months – all were minor. The Home was found to be following a transparent policy of acting upon all complaints received. Two case-tracked residents stated that they would feel able to talk to staff if they had concerns. The Manager displayed an open and committed attitude to the safety of the Home’s residents. This was evidenced by a discussion about one particular resident. The Home’s written Adult Protection procedures was examined. This document did not make it clear that the Social Services Department was the lead agency in these matters and must be contacted in the event of any suspicion of abuse. Also, it spoke of investigating matters without making reference to obtaining approval from Social Services. A discussion took place with the Manager about the need to review these procedures. The Home’s Whistle Blowing policy was seen to be very comprehensive and one member of staff confirmed that she had a copy of this - she showed good understanding of it. The Manager and her staff had been provided with Adult Protection training two weeks prior to this inspection, from a private training agency. The Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 14 Manager stated she had received Adult Protection training from Derbyshire County Council (DCC) in the late 1990s and produced DCC Reporting Forms. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 15 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): 19,21,24 & 26 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were living in an attractive and homely environment that was clean and hygienic. They had safe and comfortable bedrooms. EVIDENCE: The grounds to the premises were attractive and extensive. The Home itself was attractively decorated and furnished – it was homely in appearance. Some carpets and areas of paintwork, within and outside the premises, were in need of refurbishment. There was one assisted bathroom on the first floor, one shower room on the second floor and showers in two en-suite bedrooms. The Manager stated that the shower room was not used much by residents. She said that residents are able to have a bath every day and some do. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 16 Bedrooms of two of the case-tracked residents were inspected and found to be well personalised. All bedrooms had secure safes for personal possessions, the Manager stated. In one bedroom a portable electric heater was in use and in the other an electric heater had been permanently installed following a request by a previous resident. This indicated that residents’ needs and preferences were being taken seriously. One bedroom had had a turnknob fitted to the outside of the door at the resident’s request. It was not unlockable from the inside as, the Manager explained, the resident was unable to operate a turnknob due to arthritic hands. The Manager was able to reassure that the resident was happy with this arrangement. The Home’s laundry room had a new washing machine, with sluicing facility, and new tumble dryer. It was sited so that soiled articles were not carried through lounge areas of the Home. The Home had a satisfactory system for the transportation of soiled articles and the disposal of infected material. The Home’s Infection Control policy was satisfactory although it did not mention how soiled articles were transported around the Home. The Home was clean and odour free. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from the Home’s recruitment procedures and an adequate number of appropriately qualified staff. However, their safety was being potentially compromised by inadequate fire training for staff. EVIDENCE: The Home’ staffing rota was examined and all staffing levels were found to be satisfactory. Two waking night staff were on duty each night. The Manager explained that, in recent weeks, staff had been given financial incentives as part of a drive to improve staff retention. Case-tracked residents felt there were sufficient staff on duty. One said there was “never a long wait” for staff attention and another stated that, “They’re always there when I need them”. One member of staff spoken to confirmed this assessment. 70 of care staff had achieved a National Vocational Qualification (NVQ) in Care at level 2. The personal file of a member of care staff, appointed in February 2006, was examined. All documents required by Schedule 2 of the Regulations were in place except for a recent photograph. A Criminal Records Bureau (CRB) disclosure, in respect of another member of care staff, had not been received and the Manager spoke of chasing this. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 18 The personal file of this member of care staff included a good, detailed induction/foundation training record. Records of other staff training were examined and these indicated that staff were receiving mandatory training sessions, at appropriate intervals, except that fire training for night staff was not being provided twice a year. It was noted that staff were receiving appropriate and ongoing training on the topic of dementia. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 19 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): 31,35 & 38 Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service. Residents were living in a well managed Home. Their financial interests were being safeguarded and their health and safety promoted. EVIDENCE: The Manager had managed this Home for five years and had worked with older people for ten years. She had achieved the Registered Manager’s Award and she demonstrated skills in running the Home. The staff were very pleasant during this inspection. One member of staff stated that she enjoyed working with her colleagues: there was a “good staff team here”, she said. Other aspects of standard 32 were not assessed on this occasion. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 20 The personal finance records of the three case-tracked residents were examined and found to be satisfactory. The final balance of one of these records was successfully cross-referenced with money held. Personal money was being securely kept. The kitchen larder was tidy and ordered. Good food hygiene practices were observed in the kitchen and fly screens were in place. Cleaning materials were being kept in a secure store and ‘product data sheets’ were in place, indicating first aid measures in the event of an accident. Accident records were examined and found to be satisfactory although not being kept in date order. It was therefore not possible to analyse them for any patterns. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 22 No 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 OP9 Regulation 13(2) Requirement The three medication matters identified in standard 9 in the main body of this report must, in all future instances, be addressed. The administration of controlled drugs must be recorded in the Controlled Drug Record Book to ensure efficient auditing of their use. All information and documents, detailed in Schedule 2 of the Regulations, must be in place before staff are appointed. All staff who works night shifts must be provided with fire precaution training at least twice a year. Timescale for action 01/07/06 2. OP9 13(2) 01/07/06 3. OP29 19 Sch 2.1 23(4)(d) 01/07/06 4. OP30 01/07/06 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 Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 23 1. 2. 3. 4. 5. 6. 7. OP7 OP8 OP18 OP18 OP19 OP24 OP38 Residents’, or their representatives’, involvement in care plan reviews should be confirmed by means of a signature. All residents should have a moving and handling risk assessment. (This was a previous requirement) The Manager should undertake a refresher course in Adult Protection with Derbyshire County Council. The Home’s written Adult Protection procedures should be reviewed as outlined in Standard 18 of this report. Some carpets and areas of paintwork, within and outside the premises, should be refurbished. The bedroom door locking arrangements, in the room described in Standard 24 of this report, should be reviewed for any future resident using that room. Accident records should be kept in date order, in order to be able to analyse them for patterns. Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Brooklands (The) DS0000019949.V297811.R01.S.doc Version 5.2 Page 25 - 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. 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