Care Home: Brookdale Nursing Home

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What the care home does well The Home provides a generally comfortable and homely environment and offers a good range of interesting leisure/social activities consistent with Residents` capabilities. What has improved since the last inspection? What the care home could do better: Whilst it is accepted good progress has been made in relation to the replacement of carpets there remains room for improvement, particularly with regard to the carpet in the main lounge, which requires replacing with some urgency. The continuation of general refurbishment/redecoration would be assisted by the introduction of a written programme incorporating proposed completion dates for planned work. It is understood, and accepted, that thermostatically controlled valves for hot water taps in bedrooms are fitted when the Resident occupying that room is assessed as `being at risk from scalding`. However, the Home should undertake a review of the risk to Residents who are ambulant, have dementia, and may be likely to access other Residents bedrooms where hot water temperatures may not as yet be regulated. This is further exacerbated by the fact that bedrooms do not have locks fitted. CARE HOMES FOR OLDER PEOPLE Brookdale Nursing Home 16 Blakebrook Blakebrook Kidderminster Worcestershire DY11 6AP Lead Inspector Keith Salmon Key Unannounced Inspection 26th October 2007 09:45 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 Brookdale Nursing Home DS0000004100.V348467.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. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookdale Nursing Home Address 16 Blakebrook Blakebrook Kidderminster Worcestershire DY11 6AP 01562 823063 01562 823150 chris.bradley@redwoodcare.co.uk 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) Alder Meadows Limited Mrs Elizabeth Ann Ruth Baker Care Home 40 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40), Terminally ill (3) Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user under the age of 65 years in the category of old age (OP). 14th November 2006 Date of last inspection Brief Description of the Service: Brookdale is a care home for older people, registered to provide nursing and personal care. A two storey, listed, Georgian building, situated in a pleasant residential area of Kidderminster, the property benefits from being close to all local amenities. Accommodation comprises single and double bedrooms, with separate lounge and dining areas. There is a garden to the rear of the property with car parking available to the front. Fees at Brookdale currently range from £469.00 to £522.00 per week with additional charges being made for hairdressing, newspapers, and chiropody (private). Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced ‘Key’ Inspection commenced at 9.45am, concluded at 4.00pm, and was conducted by Mr Keith Salmon. Present throughout the Inspection, and on behalf of the Home, was the Matron/Registered Manager, Mrs. Elizabeth Baker. The Proprietor, Mr. G. H. James, was present for a period during the Inspection. In addition to inspection of ‘Key’ Standards, this Inspection also sought to review progress in meeting ‘Requirements’ arising from the most recent Unannounced ‘Key’ Inspection (November 2006) and previous inspections. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas/staff files, plus a range of other documents/records reflecting the general operation of the home. The review of documentation incorporated the ‘case tracking’ of four Residents (two recently admitted and two selected at random), comprising a full perusal of all documentation relating to each person, from pre-admission assessment to the date of this Inspection. In addition, the Inspector undertook one to one discussion with each of the ‘case tracked’ Residents. Individual discussions were also held with 3 other Residents, the Matron/Registered Manager, several members of staff, and the Proprietor. What the service does well: What has improved since the last inspection? The Manager and Staff have worked determinedly to successfully address 11 of the 14 Requirements cited at the previous Inspection, a number of which were outstanding from earlier Inspections. These efforts have resulted in improvement under several areas of care provision, including:• • • • • • Information to Residents/supporters Care planning documentation Medicines administration Lighting within the Home Staff numbers Staff recruitment/appointment documentation and Staff training Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 6 In addition, the remaining 3 Requirements, listed below, have been partly addressed but will necessitate further work. • Risk assessment with regard to Residents potentially at risk from scalding (see below) • Refurbishment and redecoration including replacement of some carpets • Some aspects of health and safety 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. The summary of this inspection report can be made available in other formats on request. Brookdale Nursing Home DS0000004100.V348467.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 Brookdale Nursing Home DS0000004100.V348467.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Residents, and/or their ‘supporters’, are now provided with information, which enables them to make a decision as to the home’s ability to meet care needs and lifestyle wishes. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied. The findings are utilised to ensure appropriate placement and care provision. EVIDENCE: Two Requirements arose from the previous inspection, i.e. • • “The service users guide and if necessary the terms and conditions must be amended in line with recent changes to the regulations.” “A letter confirming the homes assessment and the ability to meet care needs must be sent to potential residents or their representative.” Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 9 The Home’s information brochure, which incorporates the ‘Service User Guide’ has been revised and now meets the requirements of the Standard. With regard to the second ’Requirement’ the Inspector was informed the Manager had reviewed and revised procedures to ensure all new Residents now receive an appropriate ‘Terms and Conditions’ Contract/Document. A review of recently admitted Residents, including the four who were case tracked demonstrated • Appropriate and thorough care needs assessment is undertaken by the Manager, prior to admission. Information gathered is utilised in enabling an informed decision regarding the Home’s capability in meeting the individual care needs of each prospective Resident. All recently admitted Residents have suitable ‘Terms and Conditions’ contract/document and progress is being made to ensure all existing Residents are issued with the same provision. • Both Requirements are considered met. Brookdale Nursing Home DS0000004100.V348467.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in the content, organisation of care plans, and quality of entries indicate Residents’ individual assessed care needs are now being more reliably met. With medication records now being satisfactorily completed the storage, reception, disposal, and record keeping, relating to medicines’ administration are all in accordance with accepted ‘good practice.’ The care provided is delivered considerately and effectively with Residents’ privacy and dignity being respected. EVIDENCE: At the previous Inspection, held in November 2006, three Requirements were cited in respect of this ‘outcome group’. The Inspector at that time noted particular concerns regarding the completion/utilisation of care plans, and lack of entries in risk assessment documentation. Requirements issued were Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 11 • • • “The registered manager must ensure that care plans are in place and up to date to ensure that care needs are identified and met.” “The registered manager must ensure that risk assessments contain sufficient detail and kept up to date to enable care needs to be met.” “The trained nurse must sign for medication given to residents on admission.” During the intervening months the Manager has undertaken a full review of documentation design and, as part of staff supervision sessions and staff meetings, has continually reminded staff of their responsibilities in relation to care planning documentation and completion of all daily records. A review of care planning documentation evidenced a marked improvement in this area of service provision. With regard to shortfalls in the home’s administration of medicines, the Manager agreed the previously reported ‘gaps’ in Medicine Administration Records (MAR) sheets, e.g. failure to record a staff member signature following administration, or inappropriate use of codes signifying omission of administration, were a reflection of poor staff performance. As with the other Requirements under this ‘Outcome Group’, this shortfall has been remedied by constantly reminding staff of their responsibilities, and the Manager now undertakes a weekly audit of medicine administration. Further to these discussions, the Inspector completed a thorough review of medicine storage provision, medicines reception/disposal, and administration records, which demonstrated the home’s practices, meet the guidelines of the Royal Pharmaceutical Society. All three Requirements are considered met. Residents consulted were complimentary regarding staff and the quality of care provided. Throughout the visit the Inspector observed nothing that would suggest Residents’ privacy and dignity is not upheld. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their life style, social activity and keep in contact with family and friends. A good range of activities is offered, and which are consistent with Resident’s capabilities and expectations. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on Residents’ preferences. EVIDENCE: The home has an ‘Activities Coordinator’, who, since the previous inspection has increased their attendance from 2 to 3 days per week. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 13 In addition, two designated members of Care Staff, who have ‘extra’ responsibility to assist in the planning and organisation of leisure/social activities for individual Residents and as groups, support the Coordinator. The daily ‘Activities Log’, and discussion with Residents, evidenced a wide variety of activities are available. These included escorted group trips to local pubs for meals, and to Bewdley for fish and chips, visits to local parks and garden centres, shopping in Kidderminster Town Centre, or sometimes just a ‘walk around the block’, entertainment by visiting singers, reminiscence sessions, reflexology, ‘pampering by beauty sessions’, quizzes, bingo, craft sessions (currently making Christmas cards) and ‘knit and natter’ mornings’. Residents confirmed to the Inspector they are able to influence the range/nature of activities through regular Residents’ Meetings, and further commented they participated in, and enjoyed, most of the sessions, whilst others appreciated the opportunity to exercise their right to miss out if they wished. The Home receives regular visits from clergy, with monthly Holy Communion for Church of England, Baptist, and Methodist service followers, and weekly visits for Holy Communion from the local Roman Catholic Priest. Since the previous Inspection menus have been reviewed and changes implemented to reflect Residents’ preferences. This review followed information gleaned at Residents’ meetings, plus 1:1 discussions with the chef. Residents informed the Inspector the meals were very much to their satisfaction in terms of quality and quantity. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that Service Users and relatives feel their views are listened to and acted upon. Robust procedures and practices are in place to ensure that individuals are protected from abuse. Service users are provided with up to date information about adult protection. EVIDENCE: Evidence was observed confirming that all Policies and Procedures relating to ‘complaints and protection’ have been reviewed and revised. The Home now has a complaints procedure, which is clear, relevant and includes contact details for the Commission. A copy was observed displayed in the hallway of the home giving ready access to interested parties. By way of completed in-house questionnaires, and comments to the Inspector, Residents and relatives indicated they are aware of the home’s complaints procedure, and would feel confident in raising matters that concerned them. Since the previous inspection, held in November 2006, there have been no complaints made to the Home or to the Commission. Training records evidenced an ongoing programme of staff training in relation to complaints and the protection of vulnerable people. Brookdale Nursing Home DS0000004100.V348467.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a reasonably comfortable, generally safe, environment. However, some areas of the Home remain in need of refurbishment/upgrading. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, is available, and appropriately serviced and maintained. EVIDENCE: At the Key Inspection, held in November 2006, the Inspector’s ‘Judgement’, was… “Improvements to the standard of the home’s environment had continued, in order to provide Residents with a comfortable place to reside where care needs can be met, but that some refurbishment was still needed to provide a more comfortable and safe environment.”… This judgement was reflected in four Requirements being issued relating to ‘Environment’. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 16 At this Inspection it was apparent some progress has continued to be effected, which have, in part, addressed the Requirements. Specifically, the Requirements from that inspection were as follows 1. “All areas of the home including carpeting must be in good repair and suitable to the needs of persons within the home.” Evidence of progress observed included:• • • Carpets have been replaced in several bedrooms and an upstairs corridor Carpets for fitting in three bedrooms, are ‘onsite’ – fitting is awaiting replacement of radiator control valves in each bedroom with completion expected by the end of November Some bedrooms have been redecorated and new curtains fitted However, the Inspector noted the carpet in the main lounge is in urgent need of replacement, with this Room being the only public/communal room, which had an odour of stale urine. In view of this, and in order to ensure the safety, comfort, and health of Residents, it will be a ‘Requirement’ this carpet be replaced as priority. In addition it will be a ‘Recommendation’ an ongoing written redecoration/refurbishment programme, with proposed completion dates, be established and a copy sent to the CSCI for information. 2. “The registered person must assess the lighting throughout the building to ensure that it is sufficiently bright to maintain a safe environment for residents and others.” An assessment of all lighting provision within the Home has been undertaken with the resultant improvement, in some instances, created by increasing the wattage of light bulbs. This Requirement is met. 3. “The registered manager must ensure that water temperatures and room temperatures are within safe limits while also comfortable to meet individual care needs.” The detail underlying this particular Requirement is founded on the National Minimum Standard 25.8, which forms part of the overall Standard aimed at ensuring an outcome in which…. “Service Users live in safe, comfortable surroundings.” Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 17 The section of the Standard statement relevant, in the context of the above Requirement, is that hot water should be delivered to outlets at a temperature “…close to 43o Celsius”. Since the previous Inspection the Commission, in consultation with other agencies, including the Health and Safety Executive, has reviewed its position regarding the application of this Standard. The outcome of these discussions was to determine that it is unlikely temperature monitoring valves (i.e. thermostats) are needed on wash hand basins. However, where such valves are not used a risk assessment must be carried out to identify the scalding risk of individual Residents. The Inspector found documentation, in Resident’s Care Plans sampled, demonstrating risk assessment to have been undertaken. In addition the temperature of hot water at each outlet is regularly tested and the findings posted on a chart in the bedroom – temperatures in a range from 52o Celsius to 59o Celsius were seen. Although it may be considered that the Requirement (as stated above) and, in that context considered to be met, a concern of the Inspector is the Home cares for Residents diagnosed with moderate to severe dementia, some of whom are ambulatory and may, therefore, access the bedrooms of other Residents who have been risk assessed as…‘not at risk from scalding’. This possibility is compounded by the fact that any bedroom can be accessed as none of the bedrooms have a locking facility – the provision of suitable locks is the subject of a previous, and ongoing, ‘Recommendation’ by the Commission. Therefore, in an attempt to ensure the safety of all Residents a further Recommendation will be that risk assessment is undertaken in the context of Residents who may be at risk from scalding accessing unregulated hot water outlets. 4. “Review and risk assess infection control measures within the laundry area.” The Home is currently in the process of addressing this Requirement in the context of a substantial upgrading/revision of services situated in the basement area of the home, which will involve facilities within the laundry and the sluice. In view of this, and in recognition of planned work, the essence of this Requirement will be retained, but cited in the form of a ‘Recommendation’. This ‘Recommendation’ will address infection control in the context of wash hand basins in the laundry (and also in sluice rooms). The Inspector noted the hot water supply to wash hand basins in these areas, as with the rest of the Home, are not regulated by thermostatic Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 18 valves. This situation makes it difficult for Staff to adequately, and safely, wash their hands when needed (e.g. handling body fluids or contaminated clothing) as the very hot water issuing from the hot tap requires mixing hot and cold water to achieve a usable temperature to enable effective hand-washing – it is accepted by the Manager that time constraints may mean staff do not always do this. Furthermore, the rather large ‘Belfast’ sink in the laundry would not readily facilitate filling and mixing to achieve a comfortable hand washing temperature. In view of the above findings, and to ensure safe practice and maintenance of infection control, it will be a ‘Recommendation’ that thermostatic valves, or suitable mixer taps, are installed to all basins in sluice rooms and laundry. A further ‘Recommendation’ will be a small basin be installed in the Laundry for the sole purpose of washing of hands and, until this is implemented, a notice be placed by the Laundry sink advising ‘For Washing of Hands Only’. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels have shown improvement and are currently able to ensure the provision of safe care to Residents. Recruitment procedures are sufficiently robust to ensure that Residents are not placed at risk. Staff receive training, which enables them to be competent to carry out their role in providing safe care to Residents. EVIDENCE: Review of the duty roster, and observation of numbers and skill-mix on duty during the Inspection demonstrated that, in addition to the presence of the Manager on 5 days per week (at least), the Home operates the following minimum shift cover: 8.00am – 2.00pm 2.00pm – 9.00pm 9.00pm – 8.00am I RGN 7 Care Staff I RGN 4 Care Staff I RGN 2 Care Staff The report from the previous Inspection identified three Requirements relating to the ‘Staffing’ Outcome Area Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 20 • • • “The registered persons must reviewing and monitor staffing levels in particular around teatime to ensure that care needs are met.” “Recruitment procedures must be robust as to safeguard residents.” “The registered manager must ensure that all staff undertake mandatory training.” During the intervening 12 months the Manager has increased staffing in late afternoon/early evening so as to provide a cooked meal on 3-4 days per week with the aim of extending this to at least 5 days per week. However, this will be dependent upon recruitment of staff to work these times. Residents reported they like the occasional cooked meal in the evening, but also like the option of sandwiches and cakes. An additional benefit of this is that staff are not detracted from the direct provision of care, or in danger of carrying out a mix of tasks not consistent with good infection control practice. This Requirement is met. However, it is ‘Recommended’ the Manager continues to endeavour to recruit staff to extend this ‘evening catering’ cover. Staff employment files relating to the three most recently employed staff were reviewed. These demonstrated recruitment practices at the home to be satisfactory, with all elements required by Care Homes Regulations being completed, and evidence retained on file. This Requirement is met. From a total of eighteen Care Staff, ten have attained NVQ (National Vocational Qualification) Level 2, and the Manager informed the Inspector that three recently recruited staff are due to commence NVQ Level 2 training during the week immediately following this Inspection. Therefore, the Standard requiring 50 of Care Staff to hold NVQ Level 2, or higher, has been achieved. The Quality Assurance Manager for the parent company plans all training needs within the home and maintains an up-to-date training matrix. In addition, a Deputy Manager has now been engaged, who holds staff training qualifications. The holder of this post is required to manage the induction and supervision of newly appointed staff, together with supervision of some of the more experienced staff. As reflected in the above Requirement a number of shortfalls in training were previously identified. Training records now demonstrate induction training, initial mandatory training and necessary refresher training are being provided. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 21 These training sessions include - moving and handling, medication administration, dementia awareness (including management of challenging behaviour), adult protection, care planning, risk assessment, infection control, and fire awareness. In addition, future training dates are also clearly set out on the training schedule matrix. This Requirement is considered met. Brookdale Nursing Home DS0000004100.V348467.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified, and experienced person manages the home. The systems for consultation with Residents have improved, with evidence suggesting their views are acted upon. Health, safety, and welfare of service users, and staff, are promoted by safe working systems being in place. However the situation regarding more thorough and far-reaching assessment of Residents in relation to risks from scalding should be completed. (See Environment above). EVIDENCE: Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 23 The Registered Manager is a first level nurse who has worked at Brookdale for 12 years, the past two years as Manager, and is currently studying NVQ Level 4 (Management). Through observation, both direct and indirect, it was clear to the Inspector there are clear lines of responsibility within the home. Since the previous Inspection the Manager, has had an enforced absence due to a severely injured ankle, but has returned to begin leading the staff team in making some progress towards meeting Requirements in relation to ‘Management’, i.e. • • “The registered manager must ensure that care records and other sensitive documentation is kept secure at all times.” “The registered manager must ensure that safe systems are in place in line with the homes fire risk assessment.” The Manager has carried out a risk assessment with regard to records located in the ‘Nursing Office’, concluding that although the office is not locked, it’s position and the fact it is occupied for much of the time, or in sight of passing staff, the risk of files being accessed by persons not entitled to access same is very low to non-existent. Residents’ Care Plans are located within a lockable notes trolley, and all staff records are kept in a locked cabinet to which the Manager only has the access. When set against the need to facilitate ready access to care planning records by care staff, and answering the telephone, it is felt, on balance, that to lock the room when not in use would interfere with the smooth running of the Home. This conclusion is accepted and the Requirement met. With regard to the home’s fire safety systems the main concern was the lack of a written evacuation procedure. The Home now has an evacuation procedure, a copy of which was observed by the Inspector, and review of staff records confirmed staff training in fire safety to be up-to-date as were other fire safety records, e.g. fire alarm testing. This Requirement is met. A certificate of public liability insurance was on display, confirming Residents’ personal belongings are insured up-to the sum of £500.00. The Manager stated the Home has no involvement in keeping of Resident’s personal monies. Expenditure incurred for items such as hairdressing is met initially by the Home and invoiced to Residents’ representatives. The ‘Quality Manager’ for the parent company carries out extensive reviews of the service offered at Brookdale. Documents observed demonstrated a high incidence of compliance to National Minimum Standards. In areas where shortfalls were identified appropriate remedial action had been taken. The Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 24 organisation regularly carries out surveys amongst Residents/Relatives/ Representatives and GP’s to gain feedback regarding the level of service offered within the home. At the time of this inspection no potential hazards were identified and a review of relevant records provided evidence that Health and Safety Policies/ Procedures/Practices are satisfactory, with all COSHH requirements met. Records were observed providing evidence the Home has satisfactorily undertaken appropriate maintenance of equipment, including electrical, lifts, hoists, and gas appliances. Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 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 2 2 X X X X 2 2 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 X X 2 Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP8 Regulation 13 (4) Requirement The registered manager must ensure that risk assessments contain sufficient detail and are kept up to date to enable care needs to be met. All areas of the home including carpeting must be in good repair and suitable to the needs of persons within the home. The carpet in the main lounge should be replaced as priority. Timescale for action 31/12/07 2. OP19 23 (2)(b) 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP24 Good Practice Recommendations It is Recommended an ongoing written redecoration/ refurbishment programme (with proposed completion dates) be created and a copy sent to CSCI for information. It is Recommended Residents should be provided with DS0000004100.V348467.R01.S.doc Version 5.2 Page 27 Brookdale Nursing Home single action locks on their bedroom doors to provide privacy and means of escape in the event of a fire. 3. OP25 It is Recommended that a risk assessment be undertaken to assess the ‘risk of scalding’ to all Residents in areas (including other Residents bedrooms) to which they may gain access. It is Recommended that thermostatic valves or suitable mixer taps be installed to wash hand basins in all sluices and the laundry. It is Recommended that a small wash hand basin be installed in the Laundry. It is Recommended that until a small wash hand basin has been installed in the Laundry a waterproof notice be placed by the Laundry sink stating ‘For Washing of Hands Only’. It is Recommended’ the Manager continues in trying to recruit staff to extend ‘evening catering’ cover. 4. OP25 5. 6. OP26 OP26 7. OP27 Brookdale Nursing Home DS0000004100.V348467.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office The Coach House John Comyn Drive Perdiswell Park Droitwich Road Worcester, WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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