Inspection on 11/07/06 for The Rosemary Care Home

This inspection was carried out on 11th July 2006.

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

The inspector 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 Rosemary Care Home 29/03/10

The Rosemary Care Home 03/02/10

The Rosemary Care Home 08/10/09

The Rosemary Care Home 26/08/09

The Rosemary Care Home 26/06/08

The Rosemary Care Home 03/07/07

The Rosemary Care Home 29/01/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brooklands Care Home 13 Newhey Road Milnrow Rochdale Lancashire OL16 3NP Lead Inspector Diane Gaunt Key Unannounced Inspection 11th July 2006 08:15a 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 Care Home DS0000066311.V298165.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 Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands Care Home Address 13 Newhey Road Milnrow Rochdale Lancashire OL16 3NP 01706 650429 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) Din T Vanat Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability over 65 years of age (1) of places Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 27 service users, to include: Up to 26 services users in the category of OP (Older People) Up to 1 service user in the category of PD(E) (Physical Disabilities over 65 years of age) The service should employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection and whose performance is monitored and appraised at 4 monthly intervals from the date of this registration. This condition will be reviewed by the Commission for Social Care Inspection no later than February 2007. A maintenance and renewal plan must be produced by 01.04.2006 and met within a timescale agreed by the Commission for Social Care Inspection. This plan must include any outstanding environmental requirements. Planned activities both in-house and in the community must be provided to meet the assessed individual and group needs of all residents by 01.04.2006 Medication records must be completed in full, including staff signature on administration A quality assurance system must be developed and operated in the home by 01.08.2006 A Statement of Purpose and Service User Guide which accurately described the service and complies with Regulations 4 & 5 of the Care Home Regulations 2001 must be written by 01.04.2006 Not applicable 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Brooklands is a privately owned residential home which provides care for up to 27 older people and one person with a physical disability. The home is in the centre of Milnrow and is close to local shops and pubs. It provides good access to the motorway network. The home is on three floors and there is a passenger lift to all levels. Twenty one single and three double bedrooms are provided. Two of the bedrooms have the added provision of an en-suite. Two lounges and a dining area are provided on the ground floor and a lounge/dining area on the 1st floor. A bathroom is provided on each floor and a level access shower room on the ground floor. Two of the baths are fitted with fixed hoists. Toilets are located near to lounge areas and bedrooms. A well maintained garden is available to the front of the home, as is space for parking. The registered provider (i.e. the owner) agreed to make the most recent Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 5 Commission for Social Care Inspection (CSCI) report available in the reception hall. At the time of this inspection weekly fees ranged upwards from £328 - £338 per week, approximately £1422 - £1465 per month. Additional charges were for hairdressing, chiropody, newspapers, toiletries, holidays, spectacles and hearing aid batteries. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection report written since the present owner registered with the Commission of Social Care Inspection. It has been written using information held on CSCI records and information provided by people who live at Brooklands, their relatives and visitors, professionals who visit the home, the staff and the owner of the home. The inspector also visited Brooklands on 11 July 2006, the home had not been told beforehand when the inspector would visit. The inspector looked around the building and looked at paperwork that has to be kept to show that the home is being run properly. To find out more about the home the inspector spoke with five residents, the deputy manager, two carers, the cook, the domestic and the owner. Questionnaires asking residents, relatives and professional visitors what they thought about the care at Brooklands had been given out a few weeks before the inspection. Eight residents, eight relatives/visitors, one social worker and two GPs filled the cards in and returned them to the CSCI. The inspector also spoke on the telephone to three relatives and three social workers. What the service does well: What has improved since the last inspection? This is the first inspection undertaken since the change of ownership and showed that there had been improvements in the food, resident consultation and consistent staffing, as agency staff were no longer used. The cleanliness, decoration and maintenance of the building had significantly improved since the change of ownership. Residents and visitors made positive comment not only about this but about other areas also. Comments received included ‘all aspects have greatly improved since the new people took over’; ‘there has been a significant improvement since the change of ownership’. A regular visitor to the home commented that everything had improved since change of ownership. In particular they considered the person they visited was a lot happier, the food was better, and the resident looked a lot cleaner and more cared for. The inspectors observations supported these comments. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brooklands Care Home DS0000066311.V298165.R01.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 Brooklands Care Home DS0000066311.V298165.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents living at Brooklands had not been issued with contracts or information regarding the new owners aims, objectives and arrangements for care so they were not clear as to the terms and conditions of their stay. EVIDENCE: A Statement of Purpose/Service User Guide describing the service at Brooklands and terms and conditions for residents had been written. The document included information regarding terms and conditions of residence but had some inaccuracies and omissions. Although a copy had been given to the person who had moved in most recently, copies had not been given to all residents or to CSCI. One person commented that they had not received notification of any changes since the new ownership. Whilst Service Delivery Agreements were in place for those residents who were care managed, the new owner had not issued contracts to any residents, clearly stating terms and conditions of their stay. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 10 There was no written referral and admission procedure although the deputy said the home’s policy was to visit potential residents at home or in hospital prior to admission. The only admission to the home had been in an emergency and so assessment had taken place at the home on the day of arrival. The assessment was not dated or signed by the resident or their relative to show their agreement to it. A care management assessment, including a moving and handling assessment had been provided, was held on file and was signed by the resident. Brooklands Care Home DS0000066311.V298165.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual plans of care were not up to date so residents could not be sure that staff were fully aware of changing health and personal care needs. Record keeping and practices regarding medication receipt and administration were not sufficient to ensure medicines were always handled safely. Residents were treated with respect and their right to privacy upheld in the main. EVIDENCE: Four residents files were inspected. Care plans were in place on three files but had not been reviewed by care staff since April 2006. Two care plans had been reviewed with relatives and the social worker in February 2006 but the other had not been reviewed with relatives and social worker for nine months. Due to the lack of review the care plans were inaccurate in a number of areas e.g. advice given by the falls co-ordinator and dietician, changes regarding smoking, continence and behavioural issues. Relatives and some residents spoken with confirmed there had been no care plan reviews with them since the new ownership, apart from those arranged by social workers. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 12 A care plan had not been written for the most recently admitted resident although the resident had been living at the home for over 2 weeks. The care manager’s and deputy’s assessments were held on file along with risk assessments with regard to skin viability, and moving and handling. These were not dated, signed by the resident or reviewed. A low body weight was recorded for the resident on admission but a nutritional risk assessment had not been completed nor an eating plan put in place. Risk assessments were in place for the other three residents but those seen had not been regularly reviewed, one with regard to falls had not been reviewed since January. Although bedsides were in use for one resident a risk agreement had not been completed and the strategy agreed with the resident and/or relative. The deputy had begun to prepare new files which included a more recent assessment, risk assessments and new care plan format. They were not fully completed however and those documents that had been completed were not always dated so it was not possible to check their accuracy. None of this documentation had been shared with staff. The new care plan format was simpler than the previous one used and allowed space for the recording of specific action carers should take to meet residents’ needs. On completion they should be a helpful tool for staff. As seniors were responsible for updating care plans care staff said they had little involvement with them and therefore were not that familiar with their content. They said they worked from the information given at handover but that recently this had not been sufficiently detailed for them to work the shift without asking for further information. They had little knowledge of the risk assessments held on file. Weights were recorded monthly and it was pleasing to note that there had been an increase in weight for three of the residents whose care plans were inspected. The owner and staff had attended a teaching session given by a Rochdale PCT dietician about the importance of nutrition. The home had been advised about the use of the Malnutrition Universal Screening Tool (MUST) with regard to nutritional assessment but had not begun to use it. A food/fluid chart was in place for one resident and was seen to be completed with sufficient detail to monitor the resident’s diet. The dietician had been consulted regarding another resident, her advice was being followed with positive results. A turning chart was in place for one resident and staff were following verbal advice as to the frequency of turns. This advice differed than that recorded on the turning chart however. Care plans recorded GP, District Nurse and chiropodist visits but there were omissions, and hospital admissions were not clearly recorded, along with outcomes. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 13 Mixed responses were received with regard to health care. Four residents returning questionnaires said they always got the medical care they needed, three said they usually did and one said sometimes. Two relatives commented that the owner and deputy needed to be prompted to contact the GP, although the owner and deputy said this was not so. Two GPs completing questionnaires expressed satisfaction with the service and one commented that there had been a vast improvement in the service since the new owners took over. District Nurses were not always aware of which staff member was the senior on duty when they visited and staff communication and understanding was not always clear. This indicated there was room for improvement with regard to the care provided. Some conflicting information was also received regarding personal care, although the majority of residents and relatives indicated their satisfaction with the care provided. Two relatives interviewed and returning questionnaires said they were not sufficiently informed or consulted. One person had raised this with the owner and seen some improvement but was not completely satisfied with the situation. The owner said he would address the matter. Residents looked clean and well cared for and one resident said they were happier with the care taken with their clothes since the new owner came. One relative expressed concern about the laundry and said that a lot of clothes had gone missing, although staff were of the view that this was not recent. Other relatives spoken with had not experienced problems with the laundry. A record of baths/showers was held on the care plans, these showed that one person had only had two baths/showers over a number of weeks and one person had only had one bath in over 2 weeks. Staff said these were always given but information from one resident indicated this wasn’t so. Not all residents had been assessed by the Rochdale PCT Continence Nurse but the new owners were rectifying this situation and the Continence Nurse had called at the home the day before the inspection to address the matter. Arrangements were also being made for staff training in this area. Exercise for residents was limited to walking around the home and occasional ball games with the activities co-ordinator. Medication policies and procedures were in place. However inspection showed that procedures were not being followed. One resident was self-medicating and records showed that staff followed the pharmacist’s recommendation to check that the medication was taken and recorded. The owner said there was no risk assessment in place regarding this arrangement. All medicines were stored both safely and orderly. A locked cupboard was provided and the locked trolley was kept in there when not in use. Controlled Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 14 drugs were held in a locked cabinet in the office. A drugs fridge was provided, the owner said the temperature was monitored but a record was not kept. Receipt of medication was usually recorded on medication administration records but tablets were not always counted before recording the amount received. Inspection of three residents’ medication showed a disparity between the numbers recorded and those held at the home. This may have been as a result of poor practice on receipt, or of maladministration. One of the four residents’ medication checked was not counted or recorded on receipt so it was impossible to tell how much should have remained. Handwritten entries were made on the medication sheets for this resident but they were not signed, checked and countersigned. In some instances, staff had been administering medication from stock rather than from individual residents recently prescribed medication. Administration records were completed in full and codes used appropriately. GPs had been asked to review medication and there was evidence they had done so. Arrangements for the administration of controlled drugs were seen to be satisfactory. A safe system for the return of medication had been introduced and staff were using tag bags to hold unwanted medication ready for return to the pharmacist. Although the new owner had been regularly returning unused medication to the pharmacist and had a signed record of this, the home had stock piled a considerable amount of unused medication prior to the change of ownership. The pharmacy had recommended this be returned to them and the owner was in the process of preparing it for return. Staff were observed speaking to residents in a way which upheld their dignity and showed respect. Following a recent complaint the owner had taken appropriate action to ensure that all staff did so. Those residents spoken with were happy with the staff’s attitude. One visitor considered the staff to be ‘brilliant’ but added that the resident would tell staff if they were not happy with their approach. Residents and staff considered privacy needs were upheld and staff were able to give some examples from their practice. Lockable space was provided in each room although not all residents had a key. Safety locks were not fitted to residents bedroom doors and although some care plans had agreements on file that residents did not wish to have a bedroom key, they were unsigned. Only one resident had a key which was for a star lock With the exception of the owner, who is a nurse, all staff responsible for the administration of medication had undertaken or were taking medication training. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Provision of social activities had improved but was in need of further development to enable integration into community life and fully satisfy each resident’s social needs. Residents had increased choice and control over their lives which extended to the provision of nutritious and varied food. EVIDENCE: An activities co-ordinator was employed and worked at the home for 11 hours per week. The owner and deputy had spoken to residents to find out what activities they would like, although these were not recorded on care plans. Feedback from residents indicated activities had improved since the change of ownership, one said suitable activities were always available and seven said this was usually so. However, one resident, two relatives and staff commented that they could do with more activities. The activities plan included listening to music, dancing, light exercise, painting, craft work, bingo, cards and old time videos but most of these activities were not provided. The activities coordinator’s record showed that the majority of time was spent chatting, and providing nail or hair care, roles which care staff also undertook. Less regular activities included reminiscence, and occasional games. . There were no planned outings to shops or local places of interest, although the deputy said that residents had recently registered with Ring & Ride, a service the home Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 16 hoped to use for trips into the local community. A condition of registration regarding planned internal and community activities had not been met therefore. Care plans did not record residents’ religion or their wishes with regard to worship. An ecumenical visitor called regularly at the home to give communion to one resident, a priest used to call but no longer did so. The owner agreed to follow this up. He may also wish to arrange for a local church to provide a service at the home. Relatives returning questionnaires all considered they were welcomed into the home and could visit the person they wished to see in private. The choices residents made each day varied, dependent upon their mental frailty but residents who were able generally chose what time to get up, go to bed, what clothes to wear, where to spend their day and whether or not to participate in activities. They were also able to choose what to eat and where to eat it. There was evidence of each of these choices being made on the day of inspection. Two residents spoken with were eager to tell the inspector about the increased choices they had since the change of ownership. Information in the form of leaflets regarding a national advocacy scheme were available in the office at the home. Four week menus were in place and were seen to provide a balanced and nutritious diet. Of eight residents returning questionnaires the majority said they enjoyed their meals. Those spoken to were complimentary about the food and said it had improved. They valued the fact that the cook came to talk to them and would provide individual dishes to their liking on request. The cook was adjusting the menus at the time of the inspection to make them more varied and to respond to residents’ requests. She had attended a session with the dietician and was mindful of her input when adjusting the menus. Choice sheets were not always maintained for each meal and those that were in place were not always dated. As the menus were in the process of being changed this meant there was no accurate record of food served. Food served during the inspection was well cooked and looked, smelt and tasted appetising. Portions were not large but residents said they were large enough. Staff said they offered seconds but it was usually turned down. They did not do so on the day of inspection. One resident who stayed in her room was assisted with her meal and staff monitored her intake. None of the other residents needed assistance although staff were seen to appropriately prompt and encourage. Adapted cutlery was provided but plate guards were not available. The owner agreed to provide them. Jugs of juice or water were provided in lounges and residents rooms, and residents and staff said the cook cut up and served fruit in the afternoon each day. Staff and residents said that in the hot weather ice cream was provided. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 17 Suitable provision was made for those needing special diets i.e. diabetic and soft diets. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all residents and relatives knew who to go to with concerns and complaints and although appropriate systems were in place to protect residents from abuse the new owner and deputy were not familiar with them. EVIDENCE: The home had a complaints procedure but it was not displayed or distributed to residents. A short version was included in the Statement of Purpose/Service User Guide but these had not been distributed to residents either. This was reflected on the questionnaires returned to the CSCI – four relatives and four of eight residents responding were not always sure how to make a complaint. One resident had complained about a staff member’s attitude since the new owner took over and there was written evidence to show that the owner had immediately acted upon the complaint in an appropriate way. The CSCI had received no complaints about the home and the two GPs returning questionnaires said that no one had raised complaints about the home with them. An allegation regarding the theft of money from a resident had been recorded and discussed with the resident by the owner but it had not been reported to the police, Social Services Department or CSCI. A procedure for reporting and responding to allegations of abuse was available as was the Rochdale Interagency Protection of Vulnerable Adults (POVA) procedure. However neither the owner nor deputy were familiar with them, nor had they attended POVA Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 19 training provided by Rochdale Social Services Department. Staff spoken with understood the importance of reporting malpractice but were not clear about the definitions of abuse. Three carers had attended a POVA course, the rest were booked onto courses. Sufficient pre-employment Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) 1st checks were not made by the home. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 20 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic and maintenance issues were being addressed so residents felt comfortable in their surroundings. EVIDENCE: Improvement was noted in the environment since the change of ownership. The whole environment was significantly cleaner and this was commented upon by the majority of residents and some relatives completing questionnaires. One relative returning a comment card said there were unpleasant smells at the home but there was no evidence of this during this visit. The majority of residents said the home was usually or always fresh and clean. The domestic clearly took pride in her work and she is to be complimented on her achievement. She was well supported by the owner and the deputy who did some additional cleaning to make sure the home remained fresh and clean when she was not at work. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 21 Since the change of ownership, the drive outside the home had been resurfaced, some decorative work had been undertaken and a number of new lounge chairs and new carpets provided – one resident was ‘delighted’ with the new bedroom carpet. Plans were in place to decorate and carpet the entrance hall and to fit an electric shower in the bathroom. A maintenance/renewal plan had not been written, despite this being a condition of registration. These items should be included on it, as should those identified during the visit: some bedroom furniture was in need of refurbishment or replacement; a number of carpets were in need of cleaning or replacement; and some bedrooms in need of minor decorative work. The gas boiler had recently been serviced and the owner was addressing problems with the water system. A resident told the inspector that they were working with the owner to monitor temperatures and pass the information to the plumber to resolve the matter. This resident felt that they were being included in the improvement of the home and appreciated having their views sought. The gardens were seen to be well maintained and some residents spoken with said how much they enjoyed sitting out in the good weather. Sufficient aids and adaptations were provided in the home to ensure residents could move about freely and retain their independence. The Environmental Health Officer had visited the home since the last CSCI inspection and confirmed that all but one recommendation made at their previous inspection had been met. Advice given on the outstanding recommendation was being followed. A GM Fire Officer had also visited the home and identified a number of areas for action – these are addressed in the management and administration section below. An infection control policy was in place and staff interviewed were able to describe safe infection control practice. Disposable gloves and colour coded aprons were provided and changed after each contact. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry was located in the basement. All laundry was being attended to at the time of the visit indicating efficient management and provision of sufficient equipment. One relative raised an issue regarding lost laundry, although there was indication that the problem occurred prior to the change of ownership. No other residents or relatives reported any problems. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures were unsatisfactory and not all staff had sufficient training to ensure their competence so residents could not be sure that they were in safe hands at all times. EVIDENCE: Inspection of three weeks rotas showed that when the owner and deputy’s hours were included there were sufficient care hours provided to meet minimum levels. However, in the absence of a registered manager both the owner and deputy were sharing the manager’s role which was taking up a considerable amount of their time due to their lack of knowledge and experience. They recognised the need for further staffing and had advertised for a senior carer in order to give them more time to manage. Likewise insufficient domestic hours were provided although the owner and deputy also spent time cleaning to ensure a good standard of cleanliness was maintained when the domestic was not working. Agency staff were no longer used at the home which ensured that residents were cared for by a consistent group of carers who had built up relationships with them and were more familiar with their wishes. Inspection of four staff files showed that the home’s recruitment and selection procedures and the Care Homes Regulations 2001 had not been followed. Two of the four staff had been employed without the home taking a Criminal Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 23 Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) 1st check and three had been employed without written references being taken. An immediate requirement to change this practice was made. Evidence of staff qualifications and training were held on file, although recent photographs of staff member were not. In-house induction took the form of shadowing the deputy manager. Induction training which met national standards had not been provided for new employees. Six of ten carers had an NVQ level 2, as had the deputy manager. Health and safety training was arranged on an ongoing basis and a number of sessions had been booked for staff who had not received the required training to date. Dementia care training was also being provided for staff. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was not satisfactorily managed and although residents were consulted for their views, consultation needed to be further developed. Some practices did not promote and safeguard health, safety and welfare of the people using the service. EVIDENCE: The registered manager of the home resigned shortly after the change of ownership. The owner who is a registered nurse, and the deputy, who was also new had been managing the home since. The deputy manager had worked in a senior capacity in a care home previously and had begun the Registered Manager’s Award since beginning work at Brooklands. However, the shortfalls identified during this visit indicated that neither the owner nor deputy had sufficient experience or knowledge to adequately manage the home. This view was supported by feedback from two of four visiting Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 25 professionals contacted prior to this visit. The most concerning shortfalls were with regard to reporting of a protection issue; ensuring sufficient checks were in place before employing new staff; not providing sufficient up to date information regarding resident care for staff. The appointment of a suitably qualified and experienced manager is a condition of registration. Residents, staff and relatives said that they would go to the owner and deputy if there was a matter they needed addressing and they all considered them to be open and approachable. A minority of relatives did not feel that issues raised were sufficiently addressed though. There was no formal quality assurance system in place and an annual development plan had not been written. It is condition of registration that such a system is in place by 01 August 2006. However, improvements had been made with regard to resident consultation. Upon change of ownership, the owner and deputy had spoken with all residents and made a record of their likes and dislikes with regard to activities and food – although these were not held on care plans in order to inform carers. Residents’/relatives’ meetings and staff meetings had been held in both April and May but not in June or July. Items raised were seen to have been addressed. The deputy was in the process of issuing satisfaction questionnaires to residents. Her recent discussion with five residents indicated they were happy with the care, food and staff. Questionnaires should be extended to other interested parties also i.e. relatives, staff, care managers etc and their views used as contributions to an annual development plan. Other quality assurance measures which should be put into place include resident and/or their relative consultation regarding care plans and regular formal staff supervision and appraisal. All residents and relatives interviewed were happy with the arrangements regarding personal monies. The registered provider did not act as appointee for any residents. Where the home had involvement with residents’ monies, appropriate records and receipts were held. Two residents monies were checked and seen to be in order. The owner informed the inspector that a number of required policies and procedures were not in place and others were in need of review. Action must be taken to address this matter to ensure staff work consistently. The owner was monitoring health and safety training provision and had booked a number of training sessions with regard to health and safety issues. All but one domestic staff had attended a fire lecture, not all staff had had a fire practice/drill. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 26 The majority of maintenance inspections were undertaken as required. However, the annual gas inspection, thermostatic mixer valve service and legionella test were overdue. Fire precautions/equipment were regularly tested and a record kept. Action had been taken to address some issues raised on a GM Fire Officers visit in March 2006. However, a number of requirements which could affect the health and safety of residents remained outstanding. The fire officer was due to reinspect. Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 1 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X 1 2 Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 28 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&5 Requirement The Statement of Purpose and Service User Guide must be amended to accurately describe the service and comply with Regulations 4 & 5 of the Care Home Regulations 2001. Copies must be given to each resident and to CSCI. Contracts clearly stating the terms and conditions of residence should be issued to and signed by all residents or their representatives. Accurate, up to date and regularly reviewed care plans must be written and agreed with each resident and read by carers to ensure their understanding of each person’s needs and how best they should be met. Accurate, up to date and regularly reviewed risk assessments and management strategies must be written and agreed with residents and read by carers to ensure their understanding and implementation of the strategy. The registered person must DS0000066311.V298165.R01.S.doc Timescale for action 31/08/06 2 OP2 5 31/08/06 3 OP7 15 30/09/06 4 OP8 13 30/09/06 5 OP9 13 31/07/06 Page 29 Brooklands Care Home Version 5.2 6 OP9 13 ensure all medication is counted on receipt and the amount clearly recorded. The registered person must ensure that all selfadministration of medication is assessed and reviewed. The registered person must ensure that medication is offered in accordance with the prescribers’ instructions and not from stock. Planned activities both in-house and in the community must be provided to meet the assessed individual and group needs of all residents. (Condition of registration due to be met by 01.04.2006) The registered person, deputy manager and all staff who haven’t done so already must attend training with regard to Protection of Vulnerable Adults (POVA). The registered person and the deputy manager must familiarise themselves with POVA reporting procedures and follow them. A maintenance and renewal plan must be produced and met within a timescale agreed by the Commission for Social Care Inspection. This plan must include any outstanding environmental requirements. (Condition of registration due to be met by 01.04.2006) Care and domestic staffing hours must be reviewed and amended to release the owner’s and deputy’s time to undertake DS0000066311.V298165.R01.S.doc 31/07/06 7 OP9 13 31/07/06 8 OP12 16 11/08/06 9 OP18 13 30/09/06 10 OP18 13 11/08/06 11 OP19 23 11/08/06 12 OP27 18 11/08/06 Brooklands Care Home Version 5.2 Page 30 management tasks. 13 OP29 19 Staff must not be employed prior to receipt of two satisfactory written references and POVA 1st and CRB checks. This information must be sought for those staff recently employed at the home. Skills for Care induction training must be provided for all newly appointed staff. The service must employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection. A quality assurance system must be developed and operated in the home. (Condition of registration to be met by 01.08.06) Necessary policies and procedures must be written and shared with staff to ensure a consistent approach to care. The annual gas safety check, thermostatic mixer valves and legionella checks must be undertaken. 11/08/06 14 OP30 18 31/08/06 15 OP31 8 31/10/06 16 OP33 24 01/08/06 17 OP37 17 31/10/06 18 OP38 23 11/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations Assessment of potential residents should be shared with DS0000066311.V298165.R01.S.doc Version 5.2 Page 31 Brooklands Care Home them prior to admission and a record of their agreement held on file. 2 OP8 Detailed handovers should be provided at each staff change to ensure they have sufficient up to date knowledge to provide the care needed. All residents should be bathed at least weekly unless there is a recorded reason why this should not happen. A record should be kept of the drug refrigerator temperature. Handwritten entries should be checked, signed and countersigned. The owner should clearly establish the role of the activities co-ordinator and that of care staff and encourage to activities co-ordinator to offer a more suitable and varied activities programme including trips within the local area. An accurate record of food served at the home should be kept. Safety locks should be fitted to bedroom doors and each person given a key to their door and lockable space on admission unless risk assessment indicates otherwise. 3 4 5 6 OP8 OP9 OP9 OP12 7 8 OP15 OP24 Brooklands Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Care Home DS0000066311.V298165.R01.S.doc Version 5.2 Page 33 - 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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