Care Home: Brook Lane Rest Home

Similar services:

• St Vincents
• The Cotswold Home
• Winton House
• Rush Court
• Hillyfield Rest Home
• The Maypole Nursing Centre
• The Briars

What the care home does well The home provides people with a safe well maintained environment that people can make their own. There is a large attractive garden which people make use of all year round. The home has an extensive assessment and care planning recording system, which they review on a regular basis, ensuring they are meeting people`s needs. Activities are provided on a daily basis, which people can choose to join in with or not. A variety of home cooked meals and cakes are provided by the cook, with a choice being provided at all meal times. Staff receive regular training and support. Interactions between staff and people living in the home were friendly and informal, with one person stating, "We are like one big family".Brook Lane Rest HomeDS0000073081.V375668.R01.S.docVersion 5.2 What has improved since the last inspection? This is the first key inspection of this home. What the care home could do better: The home needs to ensure it offers staff some practical training in the area of moving and handling to ensure people are moved in a safe manner. Hand-rails on the concrete slopes leading from doorways to outside would assist people wanting to go outside independently. Key inspection report CARE HOMES FOR OLDER PEOPLE Brook Lane Rest Home 290-292 Brook Lane Sarisbury Green Southampton Hampshire SO31 7DP Lead Inspector Michelle Presdee Key Unannounced Inspection 2nd June 2009 01:48 DS0000073081.V375668.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook Lane Rest Home Address 290-292 Brook Lane Sarisbury Green Southampton Hampshire SO31 7DP 07918 626400 01489 576604 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) Brook Lane Rest Home Ltd Miss Emma Pepperall Care Home 25 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - OP Dementia - DE The maximum number of service users who can be accommodated is: 25 New Service 2. Date of last inspection Brief Description of the Service: Brook Lane Rest Home provides personal care and accommodation for up to twenty-five male and female service users, including those who have needs associated with dementia. Brook Lane Rest Home is located in the residential area of Sarisbury and is near local amenities. The home consists of a threestorey building and secluded garden with easy access. The home has twentyone single bedrooms, twelve of which have en-suite facilities and two shared bedrooms with en-suites. There are also two lounges, a separate dining area and a conservatory. The large ground floor bathroom is fitted with hairdressing facilities. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. During this inspection (we) The Commission were assisted by the responsible individual and the manager of the home. The inspection started at 9:20am and was completed by 2:40pm. An Expert by Experience also visited the home during the inspection. An Expert by Experience is used to describe anyone who use services, who have chosen to become more closely involved with the organisation developing their skills, knowledge and expertise. Their findings have been incorporated into the report. The majority of people in the home were involved with the inspection, some in more depth than others. The majority of staff on duty were also part of the inspection. The responsible individual assisted throughout the inspection and the manager called in to assist, although not on duty. The home sent us their Annual Quality Assurance Assessment (AQAA) back on time, which detailed information on the home. A tour of the home including all communal areas, the kitchen, the laundry and some bedrooms chosen at random was taken on the day. Paperwork including assessments, care plans, menus, staffing records and safety checks were seen. A random inspection was carried out in May and the findings of that visit have been incorporated into this report. All this information has helped form judgements in this report. What the service does well: The home provides people with a safe well maintained environment that people can make their own. There is a large attractive garden which people make use of all year round. The home has an extensive assessment and care planning recording system, which they review on a regular basis, ensuring they are meeting people’s needs. Activities are provided on a daily basis, which people can choose to join in with or not. A variety of home cooked meals and cakes are provided by the cook, with a choice being provided at all meal times. Staff receive regular training and support. Interactions between staff and people living in the home were friendly and informal, with one person stating, “We are like one big family”. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Brook Lane Rest Home DS0000073081.V375668.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 Brook Lane Rest Home DS0000073081.V375668.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident the home carries out a good pre admission assessment ensuring they can meet their needs when they arrive in the home. EVIDENCE: In the AQAA we were advised, We continue to have in force a comprehensive system of pre assessment, these are usually conducted with the care and general manager, and we envisage the opportunity for care workers to accompany us in the future whilst we carry out pre assessment. As well as the system for pre admittance we offer a full tour of the service allowing those interested in our service the opportunity to understand the service we offer. Usually the Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 9 care manager and general manager welcome all prospective service users and service users’ representatives together. Trial visits are offered as standard. The assessments of two people who had recently come into the home were viewed. It was clear the registered manager had made contact with the relevant agencies already involved with the peoples care. The family had also been contacted. The manager had been to visit one person in hospital prior to admission and had gained information from the nursing staff. All this information had been transferred into a 23 page pre admission assessment. This gave clear information on why the person was coming into care and what their needs would be at this time. For the other person due to the distance it had not been possible to assess the person before they had moved into the home. However it was clear the home had taken every action to gain as much as information from various sources before the person moved in. The person was spoken to and stated they were very happy with the home and felt it was meeting all their needs. In the AQAA we were advised, We have an updated statement of purpose and service user guide available in all service user rooms and in the information document holder near the entrance to the service. During the inspection it was noted, the statement of purpose and service user guide were displayed in the entrance of the home. It was also noted these were in each bedroom seen and we were advised every person had a copy in their room. We were advised the home is creating a new document, which will have more views of the people living in the home recorded in it. The home does not provide intermediate care. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have clear care plans, which demonstrate a respect for each person and demonstrate their needs are met in the home. Medication is managed in a safe manner. EVIDENCE: In the AQAA we were informed The newly developed care planning system is extensive and contains all aspects of the service user’s daily life. There are 20 sections contained. The care plans are formulated in conjunction with the service users, service user representatives (when appropriate) and health professionals, documentation countersigned by the service user where possible. Care plan reviews are consistently reviewed and reassessed in conjunction with all other assessments contained every month’. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 11 The care plan of three people who had been in the home for various lengths of time were viewed. We were advised and could see everyone in the home now has the same standard care plan. The care plan was an extensive 20 section document. Details were clearly recorded and included information on medication, social assessment, mental capacity, nutrition, continence, oral assessment, service user assessment and communication skills. A plan of the person’s daily living needs was detailed and included action plans. Risk assessments had been completed in areas where needed. An extensive evening plan had been created. It was possible to establish the areas identified in the care plan that the person enjoyed doing before coming to live in the home had been built upon. For example the person had enjoyed gardening and a vegetable patch had been created at the home. The person was spoken to and stated they were very happy with the home and enjoyed the meals and felt all the staff were very kind and helpful. Evidence was seen that all parts of the care plan had been reviewed on a monthly basis. Where possible this had included the signature of the person. We were advised this is now part of the key workers role, on a monthly basis they have a one to one session with the service user and talk through the care plan and ensure the person is happy with the information recorded and it is an accurate reflection of their current needs. At all times the staff were in evidence. All carers had a gentle caring manner with residents and knew them all by name and what their needs were. One explained some problems one resident had with an arm which didn’t work properly and ways round that. There was a nice banter and humour from most members of staff with the residents. One member of staff said to a resident when giving them a cup of tea and biscuits, ‘Alright with that?’ Another said to a resident, ‘Your hair looks lovely.’ One member of staff, who had only been in the home for 2 weeks, was seen quietly and diligently getting on with their work and already seemed to know the residents’ names. Another new member of staff said they were pleased they now knew all the residents’ names. Care plans have clear details of all of a persons health needs. It was possible to establish when health professionals visited and what the outcome of these visits was. People spoken to confirmed they could always access their doctor when they wanted. When looking at the homes own quality audit surveys, people confirmed they felt they were called in appropriately. The home confirmed they had good relationships with the professionals who visit the home. Two doctors visited the Home during the inspection and the two residents were seen in private. One resident said when referring to her doctor who is seeing them, ‘Every attention is seen to.’ In the AQAA we were informed We have implemented a medication communication book and additional forms to ensure we have a thorough paper trail. We have adopted a double medication trolley system which allows us to store the medication system we use in a clearer system. We have purchased disposable medication pots to assist us in the constant battle against infection control. We have made our medication room more secure by having bars fitted to the window and a new controlled drugs cabinet has been installed. We self audit on a continual basis and have regular result meetings with key staff members. All verbal instructions received from our doctors surgeries are witnessed by two staff members and immediately documented. A new refrigerator has been purchased and regular temperature readings are routinely taken’. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 12 We were advised the home has recently started using a new ‘daily meds’ medication system. All medication is kept in the locked medical room in appropriate trolleys, which are attached to the wall. Staff were observed taking the trolley around the home and correctly following the drugs procedure. We were advised only staff that have completed a more extensive training programme are involved with the administration of medication. Two staff members confirmed they are now undertaking extensive medication training programme, which they felt equipped them very well to dispense peoples medication. All cassettes of medication have a photograph of the person on it. Individual plans are maintained on how people on prescribe as necessary medication should be offered to them and what signs should be looked for if people have communication difficulties. At the random inspection in March the medication of four people and their records were checked. It was found all records and stocks of medication were correct. Two of these people were on controlled medication, this was being stored and recorded appropriately and records matched the stocks held. During this visit medication was checked but the home was only into the second day of the month administration, all records were accurate. The returns book was checked and medication was being stored appropriately, which was due to be returned to the pharmacist. It was clear this happens on a monthly basis and the pharmacist signs each month. From observations on the day it was clear staff had a good relationship with the people living in the home. The atmosphere was calm and people were spoken with in a manner, which demonstrated respect. Some people were addressed by their Christian names others by their surname, their preference were recorded on their care plans. People spoken with stated their privacy was always respected. The home has recently appointed a laundress, which people reported has much improved the service. It was noted in surveys health professionals always reported they were offered to see their patient in private. Brook Lane Rest Home DS0000073081.V375668.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to follow personal interests. People keep in touch with family and friends and have nutritious meals at a time and place to suit them. EVIDENCE: In the AQAA we were advised We carry out social assessments to ensure we can understand and accommodate the individual social interests of each individual service user. We have a full activity calendar displayed in the main lounge on a notice board giving details of activities that are carried out twice daily during the week and once per day (to allow time for service user representative visits) at the weekend. Activities are reviewed monthly to ensure we meet the requests and wishes of our service users’. All residents spoken to mentioned the various activities: bingo, quizzes and skittles outside all run by members of staff ‘when they have time’. The manager said there was normally a morning and afternoon activity and some residents are taken out to do some shopping. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 14 Outside entertainers included musicians with maracas, bells and tambourines which residents played and singers also came in. There is no set programme of activities. One resident said, ‘They come and tell you when they’ve got something on, when they’ve got some spare time.’ The Owner said that they are in the process of employing an Activities Co-ordinator 3 hours per weekday. One resident said, ‘The only thing I’d like that we don’t have are some trips out. No other residents could think of any other activity that they wanted to do. Services offered were a chiropodist every 6 weeks, a hairdresser every week who was in attendance, a manicurist every 3 weeks and occasionally a Church Minister. The Owner has asked residents whether they would like to go to church, but residents said that they preferred for the Ministers to visit them at the Home. The Owner mentioned ‘Music for Health’ who come in at weekends every so often. The Home also has a link with a local Community School whose pupils come in 3 times a year to do craftwork or to talk to residents. The latter have also been tasked to come up with a garden design for the Home’s courtyard area to include raised flower-beds for the benefit of the residents. We were advised visitors can visit at any time. People spoken to confirmed their visitors can visit at any time and are always made welcome. People on the day confirmed they are offered choices throughout their day. It was clear on arrival to the home; some people had not had breakfast. We were informed this is down to people’s individual preference. People reflected there was a choice at each meal time, some people speaking of their enjoyment of a cook breakfast and a three course meal at lunch time. Residents had a choice at all meals; they are asked about breakfast before they get up in the morning and about lunch and tea several hours before the meal. Many people had their own phone and one person had a key to their own room and managed their finances with their family support. All residents spoken with went to bed and got up at the time they prefer. One resident said, ‘You can choose the times of getting up within reason.’ Another said, ‘They ask us when we arrive what time do we want to go to bed and get up.’ One resident who spends most of the day in their room likes to stay up till late in the TV lounge. Another said, ‘When I’m tired, I ask to go to bed.’ In the AQAA we were advised We cater for all diets, offering at least three alternative menu choices per meal time seven days a week. These menus have been devised in conjunction with our service users. Service user representatives are always welcomed to join us to breakfast, dinner or tea. Our daily menu is advertised on two notice boards and on the dining tables. On the day menus were displayed in the home. The cook advised he was aware of people’s diets, likes and dislikes. He confirmed there was no restrictions on the budget and could order what food he liked. The cupboards were well stocked and there was a good range of fresh vegetables and fruit. Fruit bowls were displayed around the home for people to help themselves. A resident said, ‘The meals are very good-there is a wide choice’. Lunch was either a Cornish pasty, baked beans and chips or a ham salad. Hot and cold drinks were being given out regularly throughout the inspection as well as iced lollies after lunch, as it was a hot day.Strawberries were been grown in the garden, which people stated they were looking forward to. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 15 Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident if they make a complaint it will be dealt with appropriately. Staff have adequate training to ensure procedures are followed if abuse is alleged. EVIDENCE: In the AQAA we were advised,’ any complaint raised is attended in a timely manner, investigated thoroughly ensuring all details relevant are documented and that any complaints raised are resolved as soon as possible but within 28 days. A copy of the complaints procedure has been issued to each service user and their representatives, to ensure everybody is informed of it. Complaint forms are in each service user’s bedroom and in key areas around the service. We were advised the home has received no complaints; we have also received no complaints about the home. It was noted complaints leaflets and envelopes were displayed around the home. People spoken to all felt they would be able to complain to the manager, if something was wrong. All surveys seen, reflected people were aware of the complaints process and felt confident if they raised a complaint it would be dealt with. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 17 In the AQAA we were advised, we promote and protect our service users from abuse. We ensure continual and constant compliance with the safeguarding of vulnerable adults. Training is proactively promoted and we can report that the vast majority of staff have completed our safeguarding adults certified training. Details relating to safeguarding are promoted throughout the home and staffs knowledge of whistle blowing is often asked of and reiterated to all staff members’. Certificates were seen demonstrating staff had received training in the protection of adults. Staff spoken to felt the training they had received was adequate enough to equip them to deal with an allegation of abuse, if one was made to them. Since the registration, there have been no safeguarding referrals. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a clean, safe, well maintained and comfortable environment. EVIDENCE: In the AQAA we were advised routine risk assessments have been completed and are reviewed on a monthly basis to ensure there is a safe environment for all those using the service. Any deficiencies highlighted within our daily health and safety checks are attended to without delay. We have created and maintain an environment that is now offensive odour free. We immediately react to any environmental discrepancies that occur. We have employed our own maintenance technician who is systematically upgrading and maintaining the standard of decoration within the service’. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 19 During the inspection the majority of the bedrooms and all communal areas of the home were seen. All areas were clean and decorated to a good standard. New beds, headboards and bedding have been purchased. People spoken to were pleased with their rooms and reported they were kept clean. The majority of rooms had been personalised by the resident. All windows had restrictors where necessary and the water temperature is checked and recorded on a daily basis. This was checked whilst we were in the home and found to be within a safe temperature. The home has three communal areas and a dining room. People can choose where they sit and spend their day. One area has been designated the activities area and items were displayed, that people had created. The home also had colourful art work displayed from the local comprehensive school. The home has purchased new furniture including vanity units, lockable cabinets, wardrobes, chairs and over bed tables. The home states it is a continuous process keeping all furniture of a good standard, replacing and refurbishing all items which are not acceptable. On arrival to the home an unpleasant odour was detected in one part of the home and in two bedrooms. The responsible individual explained the home is working very hard to eliminate this with regular cleaning of carpets and the treatment of wooden floorboards. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with sufficient and a well trained staff group who have all been through a stringent recruitment procedure to ensure the safety of people. EVIDENCE: In the AQAA we were advised we ensure a skill mix suitable to meet the needs of our service users and we ensure the service is adequately staffed throughout the day and night. On the morning of the inspection five carers, one domestic, one laundress and one maintenance person and the responsible individual were on duty. We were advised this is the usual staff pattern seven days a week. Four carers work an afternoon shift and two members of staff work a waking night duty, the cook works from seven in the morning until 4.30 in the evening. People spoken to reported they felt there was always adequate staff on duty to meet their needs. People spoke of a good relationship with staff members and felt it was like a large family. Staff spoken to felt there was always adequate staff on duty to be able to meet peoples needs. All comments about the staff were complimentary. One resident said, ‘The staff are very nice-I can’t complain.’ Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 21 Another said, ‘If there is something you need, you ask politely. We all love one another.’ One resident said, ‘Sometimes the staff are pushed for time, especially if someone is off sick.’ Another said, ‘I can’t grumble at all, the staff are very good and kind.’ We were advised over 50 of staff have achieved a National Vocational Qualification (NVQ) Level 2 and more staff are enrolled to start this qualification. Three members of staff are currently undertaking a NVQ Level 3. In the AQAA it stated ‘we have a thorough recruitment policy. We ensure two references are sought. We ensure protection of vulnerable adults (POVA) 1st checks and criminal reference bureau checks (CRB) are done. We ensure all new staff members are working along side other suitably experienced and qualified staff during the first few weeks of employment. We ensure mandatory training commences immediately after appointment of new staff members and that it is completed within 6 weeks. We carry out unannounced night time inspections’. At the random inspection the staffing records of two people who had started work in the home recently were viewed. All the necessary checks and references had been undertaken. The files were well organised and demonstrated when people had undertaken training. We were advised all staff are currently working through the Skills for Care Common Induction Standards. The staff records of three members of staff were viewed and all found to contain all the necessary information, checks and references. All staff spoken to confirmed they felt there was adequate training within the home. All training undertaken was recorded in staff files. In some areas the need for practical training was highlighted. Two staff were seen aiding a person to move and it was clear they were not using the correct technique. The responsible individual stated he would ensure practical training would be offered in this area. Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have confidence in the home because it is well managed. The environment is safe for people and appropriate health and safety practices are carried out. EVIDENCE: The manager of the home has many years experience in management and has gained a NVQ Level 4 and a Registered Managers Award. The manger and responsible individual work as a team and are both hands-on. Some staff Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 23 remarked that things were a lot better in the Home since the new manager and responsible individual had arrived and were helped in their NVQ training. The home actively seeks the views of people who live in the home and visit the home. Every person has a copy of the complaint procedure in their room with an envelope so they can make a complaint anonymously. A file has been started, which has copies of all the questionnaires sent to service users, their relatives and visiting professionals. Comments from care managers included, ‘atmosphere very friendly’. Another praised the manager’s communication skills. One family survey, stated, ‘The cleanliness has greatly improved’. The home has started residents meetings, with the minutes taken and available. We were advised the home analyses the results for any common trends, which they can then act on and make any necessary changes. There were vases of fresh flowers in the Home, a direct result of one of the resident’s suggestions. The Home noticeably seeks to make improvements for the residents and when confronted with a problem, they work something out. One resident was worried about his missing razor (removed for safety during the day) and a deputy manager spoke to the resident and suggested that he might like to have an electric shaver, with which the resident readily agreed. The home manages the personal allowance for the majority of people living in the home. The finances of one person were checked it was noted a clear record is maintained of all monies in and out. The monies are held in a secure place and matched the records held. It was possible to establish all staff undertaken supervision. A record is maintained, which is signed by both parties. All staff spoken to were aware of their supervision sessions and felt they were beneficial. The AQAA advised us the home has clear policies on health and safety. Regular checks are made on the equipment in the home and reports were seen demonstrating professionals’ service these. The home employs their own maintenance person who does daily checks on equipment. Staff reported they all have the equipment and training they need. The laundry was well maintained and people told us this service had recently improved. The fire log book was seen, which demonstrated all the necessary checks and tests were being done in the appropriate timescales. The responsible individual makes monthly reports on the home and employs a company to carry out these checks on a regular basis. Brook Lane Rest Home DS0000073081.V375668.R01.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Brook Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Lane Rest Home DS0000073081.V375668.R01.S.doc Version 5.2 Page 26 Care Quality Commission The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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