Care Home: Brookside House

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What the care home does well The home provides a high standard of care and support to a group of residents who have a range of complex physical care needs. The residents feel that they are supported as far as possible to maintain their independence. They also feel that they are able to make choices in their daily lives and the staff respect their views. One person said "I like living here it is very homely, the staff are kind and I can`t find anything wrong with the home". The staff demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs, especially in relation to their support needs. The residents were also observed to have a good relationship with the staff. The residents are supported to have their individual needs met by a key working system. They are also supported to access a wide range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The home has a well-established and very stable team of staff who are being supported by a manager. The home is very comfortable and homely and the residents each have their own flat that is personalised to their taste. The home also has access to a vehicle that is helpful in facilitating some of the community activities.The people living in the home are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures and health and safety procedures. What has improved since the last inspection? Since the last inspection magnetic door closures have been installed so that there is no longer a need to prop open flat doors if residents want this door to remain open. The rota includes the name of any agency staff working in the home. What the care home could do better: A few areas for improvement were identified at this inspection. In terms of the residents it was required that where they are at risk of developing a pressure sore that a clear action plan is in place to reduce the risk of this occurring. It was also recommended that the care planning system is reviewed to enable the residents to be more involved in the process and have ownership of their care plans. It was also suggested that where residents wish to do so they are supported to be more involved in the running of the service such as assisting with staff recruitment and quality assurance processes. It was also recommended that each resident has a medication profile to clarify when medication is administered by staff and when it is self-administered. Where residents are unable to sign for their monies that they have passed to the managers for safe keeping it was recommended that two staff sign to confirm movements in this cash. In terms of staffing it was required that the manager completes a training needs analysis to ensure the staff training needs are identified and training is booked as necessary. An annual quality assurance audit needs to take place in the home that seeks the views of residents, relatives and friends and other care professionals. CARE HOME ADULTS 18-65 Brookside House Ash Close Edgware Middlesex HA8 8YD Lead Inspector Jane Ray Unannounced Inspection 16th January 2008 10:00 Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 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 Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookside House Address Ash Close Edgware Middlesex HA8 8YD 020 8959 2792 020 8201 0679 adminedgware@v2net.co.uk www.grooms-shaftesbury.org.uk Grooms-Shaftesbury 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) Mrs Anna Glynn Care Home 24 Category(ies) of Physical disability (24), Physical disability over registration, with number 65 years of age (24) of places Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following category: Either whose primary care needs on admission to the home are within the following categories: 2. Physical Disability - Code PD and PD(E) The maximum number of service users who can be accommodated is: 24 This is the first inspection as a newly registered service for Grooms Shaftesbury Date of last inspection Brief Description of the Service: Brookside is a large detached purpose built care home opened by the ArchBishop of Canterbury, George Carey in 1993. The home was originally managed by the John Grooms Society, but in 2007 the ownership of the home changed to the newly formed charity Grooms Shaftesbury. The home provides care to twenty-four service users with physical difficulties and is staffed twenty-four hours a day. There are twenty-three self-contained flats set on two floors. In addition there is a large lounge and dining area that all the residents can access. There is parking to the front of the building for staff and visitors and the rear garden has been landscaped to provide a very attractive garden with a pleasant brook running to the back, hence the name of the home (Brookside House). The home is built on stilts in case of flooding from the brook. Underneath the home is storage space for garden tools. Service users are able to access the garden via a purpose built lift to carry wheelchair users. The stated aim of the home is to provide a homely environment where people with disabilities may live and be cared for with respect and dignity. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 5 The last inspection record and purpose and function document are available for inspection on the notice board at the entrance of the home. The homes fees currently range from £850 to £1050 per week. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 6 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. The inspection took place on the 16 January 2008 and was unannounced. The inspection lasted for five and a half hours and was the key annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to speak to and observe the support given to some of the current residents. The inspector was also able to spend time talking to the deputy manager as well as two members of care staff, the cook and the activity co-ordinators who were working in the home. The inspector did a tour of the premises and also looked at a range of records including resident records, staff files and health and safety documentation. The home had provided the inspector with a completed self-assessment questionnaire (AQAA) prior to the inspection. In addition the inspector received completed surveys from two residents, two care professionals, two staff and five relatives. What the service does well: The home provides a high standard of care and support to a group of residents who have a range of complex physical care needs. The residents feel that they are supported as far as possible to maintain their independence. They also feel that they are able to make choices in their daily lives and the staff respect their views. One person said “I like living here it is very homely, the staff are kind and I can’t find anything wrong with the home”. The staff demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs, especially in relation to their support needs. The residents were also observed to have a good relationship with the staff. The residents are supported to have their individual needs met by a key working system. They are also supported to access a wide range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The home has a well-established and very stable team of staff who are being supported by a manager. The home is very comfortable and homely and the residents each have their own flat that is personalised to their taste. The home also has access to a vehicle that is helpful in facilitating some of the community activities. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 7 The people living in the home are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures and health and safety procedures. What has improved since the last inspection? 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. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 5 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will be assessed and that the service can meet their needs. They are also provided with information about the home in order to help them decide if the service is where they want to live. EVIDENCE: The statement of purpose and service user guide were inspected. Both of these documents are in a user-friendly format and are clearly written, accurate and contain all the necessary information. The surveys completed by the residents said that they felt they had received enough information about the service when they moved in. Four case notes for people living in the homes were inspected and these all contained detailed assessments as part of the person centred plans prepared by the home. One person has been admitted to the home during the last year. She had an assessment provided by an appropriate care professional. The deputy manager also explained that her previous home had provided copies of Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 10 her care plan. The resident said she had “made five visits before moving into the home” and felt that her move had gone well. The inspector discussed the current needs of the people living in the home with the care staff. They felt they had received the training necessary to meet the needs of the residents. This includes training on promoting equalities for the residents. The surveys returned by relatives said that they felt the home always or usually met the needs of the resident. The inspector looked at the contracts between the home and the residents for four people who live in the services. They all had a contact in place that included all the necessary information and was correctly signed. This again was in a clear user-friendly format. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,8 and 9 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home feel able to have control and make decisions in their daily lives. Each person has a care plan but there is scope for greater ownership of this plan by the residents so they feel it reflects their individual aspirations. EVIDENCE: Four case notes for the people living in the home were inspected. Each person has detailed individual person centred care plans. These incorporate a few goals that have been agreed at their review meeting. Everyone living in the home had their care plans reviewed on a monthly basis by their key worker. All of the people living in the home had participated in a review meeting with their key worker and a senior carer in the last six months. The record of this meeting had been prepared and was available in each person’s case notes. The deputy manager said that most residents had also had a review meeting with Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 12 their care manager in the last year, but in the records that were inspected there was no record of this meeting available. This meant it was not possible to see if any action agreed at this meeting had been implemented. When the residents were asked about their care plan they were not able to discuss what it contained and it did not appear to be very meaningful for them. The four people living in the home all had a named key worker. Two members of staff when asked about their key worker role were able to describe fully how this is implemented, including going out with the resident and attending their review meetings. One resident said she did find it difficult to decide when she wanted assistance, whether it was something she needed to do with her key worker or if it was support any member of staff could provide. This would probably be something worth discussing at a residents meeting. It was observed that the staff were communicating very effectively with the residents and clearly knew how to respond to their requests. One resident said, “I just tell the staff what I need and it will happen”. Specific requests such as same gender care at all times were respected and recorded in the case notes. The four residents whose case notes were inspected and included individual risk assessments covering areas of potential risk such as moving and handling and pressure care. It was noted that for the pressure care risk assessments that there was no record of the action taken to reduce the risks for people who were identified as having a high risk of developing a pressure sore. The residents told the inspector that there is a monthly residents meeting. One resident showed the inspector the minutes of this meeting. She said this offers them an opportunity to discuss what is happening in the home. One resident said they would like to be more involved in making decisions about the home. She said she had previously helped with staff recruitment and would like an opportunity to do this again in the future. The deputy manager said that none of the residents currently has an advocate although most can express their own wishes and have the support of relatives and friends. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11,12,13,14,15,16 and 17 People using this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to have full and active lifestyles, both in the home and in the community that reflect their interests and offer opportunities for the development of new skills. They also develop and maintain family and personal relationships. EVIDENCE: The activity staff and residents explained that the people living in the home are supported to access a range of activities based on their individual needs and interests. On a monthly basis the activity staff meet with each of the residents to discuss their individual choices for activities. This includes attending college courses. Some residents also work in a voluntary capacity and help at a day service or help children with reading at a local school. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 14 The leisure activities the residents participate in are very varied and include going to shows, shopping, bowling, concerts, swimming, pony trap riding and eating out. In addition there are lots of activities that take place within the home including bingo and quizzes. The home is obviously a very social environment and there is an annual barbecue, Christmas party and a trip to the seaside. The residents all talked about how they spend their time and it was evident that their lives were as busy and active as they wanted them to be. The residents have access to a vehicle that is wheelchair accessible but also make use of other forms of transport such as taxis. The AQAA showed that a number of the resident’s are practicing Christians. One resident explained that the residents attend a number of different churches based on their individual choices. It was evident that the residents felt comfortable practicing their religion. One resident told the inspector that she was Jewish but did not wish to practice her religion. A married couple living in the home share a flat. The other residents said that they had formed close friendships with each other and maintain contact with family and friends. One resident said, “my family can visit whenever they want”. The deputy manager said that the residents are offered as much privacy as they want in their flats to have the space to develop their personal relationships. The home offers an ideal environment for people who want to maintain or develop their independent living skills. Each flat has its own kitchenette and residents can also have their own washing machine. One resident said she likes to prepare herself a cooked breakfast in the morning in her flat. Another resident said the staff put her washing into her machine, but she switches it on when she chooses to do so. The residents explained that the routine depends on each person and their activities. The residents spoken all talked about their different routines and this clearly reflected their individual choices and not the needs of the service. The deputy manager explained that since the last inspection the staff working in the morning, have started their shift fifteen minutes earlier to support the residents who have said they want to get up a bit earlier. The residents all said how much they enjoyed the food. The home has a team of catering staff who prepare a main meal at lunchtime and a lighter meal in the evening. Sometimes the care staff also help prepare the evening meal as the home has one vacant kitchen assistant post. In addition to the food on the menu the cook showed the record that demonstrated that he speaks to the residents to ensure he meets their individual preferences. One resident is a vegetarian and she said the cook prepares the food she wants to eat. Lots of fresh fruit and vegetables were available and the cook confirmed they have been supported by a dietician to prepare a menu based on healthy eating Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 15 principles. During the inspection lunch took place and this was a relaxed social occasion and staff eat with the residents. In addition residents can prepare themselves drinks and snacks from a small kitchen area based in the communal lounge. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will receive personal and healthcare based on their individual needs and choices. Residents are supported to manage their own health where they wish to do so through for example administering their own medication. EVIDENCE: It was observed during the inspection that the people living in the home were very well presented. The residents were able to tell the inspector how they have a hairdresser who visits the home as well as using local hairdressers. They also said how they go shopping to buy their clothes. They said they receive the support they need to meet their personal care needs. One resident has very high care needs and an individual arrangement is in place for her to have additional staff arranged through an agency. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 17 The healthcare records were inspected for four of the people living in the home. They had all been supported to access the GP, dentist, chiropodist and optician for their primary healthcare checks in the last 12 months. In addition the resident’s receive input for their specialist healthcare needs. The residents also have input as required from the district nurse. The home has also arranged for six hours of physiotherapy input each week. The physiotherapist sees a number of residents during this time on an individual basis as well a running an exercise class. Many of the residents have their own wheelchairs. They explained that each wheelchair has a maintenance contract so it is repaired in a timely manner when needed. The staff support the residents to clean their wheelchairs. The home uses a Boots blister pack medication system. A number of the residents self-medicate some or all of their medication and risk assessments are in place for this. The medication administration records were inspected. The medication entering the home and being returned to the pharmacy is recorded appropriately on the medication administration record. The medication administration records were slightly confusing as for some residents medication is partly administered by the staff and partly selfadministered. The administration record for the self-administered medication is left blank and looks as if the medication has not been administered. It is recommended that a medication profile is prepared for each resident stating how the medication is administered and this is placed in the medication folder. The medication available was correct and was not out of date. None of the residents have PRN medication apart from some painkillers. Training records were inspected and all the permanent staff had received medication training. The medication storage cupboard is in a separate air-conditioned room and the temperature is monitored daily. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that the correct systems are in place should they need to complain and that staff training and procedures are in place to protect them from the risk of being abused. EVIDENCE: The inspector looked at the complaints record and saw that there had been no complaints since the previous inspection. The complaints procedure was also inspected and this was in a format accessible for the residents. The residents spoken to said they knew how to complain. One person said, “I haven’t needed to make any complaints but if I did I know who to speak to and that they would sort it out”. They surveys completed by relatives also showed that they knew how to make a complaint if they needed to do so. A number of compliments have also been received by the home. These were also reflected in some of the comments received from relatives in the surveys completed as part of the inspection process. The inspector saw that the home had a protection of vulnerable adults procedure prepared by the London Borough of Enfield. The staff training Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 19 records were inspected and showed that staff had received training on the protection of vulnerable adults. The inspector spoke to two staff during the inspection and they both showed a good knowledge of the complaints and adult protection procedures. The inspector looked at the personal finances for the residents. The deputy manager explained that all residents have a bank account and then some choose to place some of their monies for safe keeping in the office safe. Residents also have a safe available in their individual flats. The record of the monies held in the office safe were inspected and included a clear record of monies being returned to the residents. It was however noted that some residents are unable to sign for their monies and it is recommended that in this case two staff should sign when money is paid in or out of the savings held in the safe. The residents were able to tell the inspector how they are supported by staff when they want to go to the bank. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25,27,28,29 and 30 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are benefiting from living in a clean and a pleasant environment. Individual flats adapted to meet the needs of the residents promote independence and privacy. EVIDENCE: The inspector toured the building with the deputy manager, all areas are fully accessible for wheelchair users, which means that residents can move freely around the home which allows them to be as independent as possible. The home has 23 flats. The flats that were inspected with the consent of the residents consisted of a bedroom, living room with kitchenette and bathroom. All of the flats inspected were found to be in good condition and very homely. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 21 The inspector noted that all the residents have keys to their flats, although some choose to leave them unlocked. One resident demonstrated a remote control mechanism she has for opening and closing the door of her flat. Since the last inspection the flat doors have been fitted with magnetic door openers that would shut automatically in the event of a fire. The dining room in the main home is bright and well furnished. There are small tables, which allow residents to sit in intimate groups. This room also has an area to prepare drinks and snacks. This space is also used for activities and can be divided using sliding doors to create a smaller area if required. The home has a communal laundry, which all the residents can use, although many have a washing machine in their own flats. The home has a very pleasant garden with raised flowerbeds. This is accessible by a lift. The inspector noted that the home was very clean and the residents said that the cleaner helps to thoroughly clean their flat once a week. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a very stable and experienced team of staff whose performance is maintained with ongoing supervision and training. Care must be taken to ensure that refresher training is booked as needed. EVIDENCE: The inspector looked at the staff rota. The staff team consists of a manager, a deputy manager, a cleaner and a team of twenty carers and eleven other staff including an administrator, catering staff, domestics, two activity staff and a handyman. The staff turnover is low with only one staff leaving in the past year and most staff working at the home for a number of years. The deputy manager explained that the home only rarely uses agency staff as there are a team of bank staff. During the day there are five care staff working. At night there are three waking members of staff. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 23 The AQAA explained that 12 of the 21 care staff have completed an NVQ level 2 or above and 9 are working towards the qualification. This means that the home has more than 50 of the care staff who have completed an NVQ level 2 in care. The recruitment checks were inspected for four staff. The staff members had the appropriate recruitment checks and contracts in place. The record of staff team meetings was inspected and these meetings take place on a monthly basis and discuss a wide range of operational issues. The staff members spoken to during the inspection confirmed they attended these meetings. The induction checklist was inspected. This consists of a comprehensive induction checklist to work through in the first few days and the first six weeks. The staff training records were inspected for four staff. These showed that staff had received most of the essential training. The training record in the home showed that in the last year training had taken place on care planning, equality awareness, medication, fire safety and moving and handling. It was however noted that some staff need refresher training and it would be helpful to have an overview of the training needs of the whole staff team so that ongoing training can anticipated and booked. The staff supervision records were inspected for four staff. The staff had all received individual supervision and this had taken place on a regular basis and included clear actions. The staff members spoken to explained that they receive regular individual supervision. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,38,39 and 42 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home is overseen by an experienced and appropriately qualified manager and senior team. Their health and safety is protected by the appropriate measures being in place. A quality assurance system needs to be implemented although residents feel that their views are listened to. EVIDENCE: The manager was not on duty at the time of the inspection but is registered and has managed the service for a number of years. The staff said that they Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 25 feel confident they can raise issues with the manager and these will be addressed. The manager has completed the registered managers award. The deputy manager was observed to be managing the home very competently in the absence of the manager and this ensures that standards in the home are maintained. The deputy manager explained that a quality assurance exercise had taken place but that this now needed to be updated and seek the views of residents, relatives and other care professionals. The health and safety training records were inspected for four staff. They had mostly completed this training although there were a few gaps with one person having no record of food hygiene training, one without a record of moving and handling training and two without a record of infection control training. This needs to be included in the training analysis for the whole staff team so that ongoing training needs can be met. The fire safety measures were inspected. The fire appliances and fire alarm had been serviced. Weekly fire alarm and emergency light checks and weekly drills are recorded as taking place. A fire safety risk assessment is available. The fire safety emergency plan is in place and the residents explained that if the fire alarm goes off they stay in their rooms as they are protected by fire doors. The self-assessment (AQAA) confirmed that current certificates were available to confirm the maintenance for the electrical installations, portable electrical appliances, lift and hoist. The current insurance certificate was inspected and was satisfactory. The record of accidents for the last six weeks was inspected and whilst there were a few falls there was nothing of concern. The deputy manager explained that accident records were passed to the head office to check and ensure issues are addressed. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 4 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 3 2 x x 3 x Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 27 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. 1. Standard YA9 Regulation 13(4) Requirement Timescale for action 28/02/08 2. YA35 18(1)(c) 3. YA39 24(1)-(3) The registered person must ensure that where a resident is assessed as having a high risk of developing a pressure sore that an action plan is in place to address this risk. The registered person must 28/02/08 ensure there is a training needs analysis for the whole staff team to identify when training needs to be arranged. The registered person must carry 31/03/08 out the annual quality assurance excercise in the home. 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 YA6 Good Practice Recommendations The registered person should introduce a system of care planning to that enables residents to become involved in and have ownership their care plans. DS0000070237.V358260.R02.S.doc Version 5.2 Page 28 Brookside House 2. YA8 3. 4. YA20 YA23 The registered person should explore ways of offering opportunities to residents to participate in the running of the home, where they wish to do so, such as assisting with recruitment or quality assurance work. The registered person should introduce medication profiles to clarify for each person, which medications are selfadministered and which administered by staff. The registered person should ensure that where a resident cannot sign to confirm receipt of their monies that two staff sign to confirm this has taken place. Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brookside House DS0000070237.V358260.R02.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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