Care Home: Brookvale Lawn

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What the care home does well All comment cards, from people living at the home, their relatives, staff and external professionals were positive about the home and service it provides to people who live there. All comments made to the inspector during her visit to the home were also positive about the service people receive. This is evident in a comment from a person who lives at the home who wrote `wonderful care and think myself lucky to be here`. The manager has a great deal of experience of managing a care home and as a consequence the home is well managed. The home has a consistent care staff team supported by all the necessary ancillary staff.The care planning system is comprehensive and details people`s preferences as to their care and daily routines. The environment is very clean and well maintained with the provider investing in the refurbishment and replacement of floor coverings and furniture on the ground floor. People were positive about the food provided at the home which meets individual likes and dietary needs. What has improved since the last inspection? Following the previous inspection two requirements and two recommendations were made. These have all been complied with. The medications trolley is now secured to the wall of the lockable room in which it is stored. The home has not recruited any new staff (other than an overseas nurse on a programmed organised by Southampton City Council) therefore recruitment records could not be fully assessed, however discussions with the manager indicated that she is fully aware of the necessary pre-employment checks which must be carried out prior to people commencing employment at the home. As recommended the home undertakes a full nutritional risk assessment and weighs all people as part of the admission process. The risk assessment tool determines the frequency of weighing after this. The manager stated in the homes Annual Quality Assurance Assessment that the infection control policy has been reviewed to reflect the day-to-day practises in the home. The home continues is programme of redecoration with a number of bedrooms being redecorated and new carpets laid. There are plans to redecorate the ground floor corridors and communal rooms following that new carpets, soft furnishings and chairs are to be provided. What the care home could do better: Overall the service provided meets people`s needs and expectations however the following requirement is made. The registered manager must ensure that the medication administration records are fully maintained with no gaps left. When medication is refused ornot required this must be recorded using the letter code indicated on the medication administration recording sheet. CARE HOMES FOR OLDER PEOPLE Brookvale Lawn 15 Lawn Road Portswood Southampton Hampshire SO17 2EX Lead Inspector Janet Ktomi Unannounced Inspection 4th October 2007 09:30 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 Brookvale Lawn DS0000011776.V347209.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. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookvale Lawn Address 15 Lawn Road Portswood Southampton Hampshire SO17 2EX 023 8057 7786 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) Brookvale Homes Limited Mrs E Raison Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2007 Brief Description of the Service: Brookvale Lawn is one of a number of residential services owned by the same proprietor. Brookvale Lawn predominately provides a service for older persons who have some degree of age related mental frailty. The home is a modern purpose built residential home situated in a residential area of Southampton, close to the local amenities of Portswood and a short ride away from Southampton City Centre. The home is staffed twenty-four hours a day by care staff and there is also a team of domestic and catering staff. The accommodation is organised over three floors, which are all accessible by a regularly serviced passenger lift. All bedrooms are designed for single occupancy and have ensuite facilities. Some rooms are interconnecting and could accommodate couples. The home has a communal lounge/dining room. Additional communal space is available on the first and second floor providing a small lounge, library, chapel and hairdressing room. There is a car park to the front of the home and small patio area. Brookvale Lawn is owned by Brookvale homes Limited and managed by registered manager Mrs Eileen Raison. Weekly fees range from £435 to £450 dependant on assessed needs. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information gained prior to and during an unannounced visit to the home undertaken on the 4th October 2007. All core standards and a number of additional standards were assessed. The visit to the home was undertaken by one inspector and lasted approximately six and a three quarter hours commencing at 09.30 am and being completed at 4.15 p.m. The inspector was able to spend time with the registered manager, deputy manager and staff on duty and was provided with free access to all areas of the home, documentation requested, visitors and people who live at the home. Prior to the visit the manager completed an annual quality assurance questionnaire, information from which is included in this report. Comment cards were returned from two GP’s. Comment cards were sent to the home for distribution to people who live at the home and their relatives/visitors. Six comment cards were received from people who live at the home and eight relative’s responses were received. Four care staff also returned completed comment cards. All comment cards contained positive statements about the home. Information was also gained from the link inspector and the home’s file containing notifications of incidents in the home. During the visit to the home the inspector was able to meet with and talk to many of the people who live at the home, staff on duty and five visitors. What the service does well: All comment cards, from people living at the home, their relatives, staff and external professionals were positive about the home and service it provides to people who live there. All comments made to the inspector during her visit to the home were also positive about the service people receive. This is evident in a comment from a person who lives at the home who wrote ‘wonderful care and think myself lucky to be here’. The manager has a great deal of experience of managing a care home and as a consequence the home is well managed. The home has a consistent care staff team supported by all the necessary ancillary staff. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 6 The care planning system is comprehensive and details people’s preferences as to their care and daily routines. The environment is very clean and well maintained with the provider investing in the refurbishment and replacement of floor coverings and furniture on the ground floor. People were positive about the food provided at the home which meets individual likes and dietary needs. What has improved since the last inspection? What they could do better: Overall the service provided meets people’s needs and expectations however the following requirement is made. The registered manager must ensure that the medication administration records are fully maintained with no gaps left. When medication is refused or Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 7 not required this must be recorded using the letter code indicated on the medication administration recording sheet. 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. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people are assessed prior to moving into the home to determine that their individual needs can be fully met. People, or their representatives, are able to visit the home prior to admission to assess the quality, facilities and suitability of the home and are fully informed as to the terms and conditions of residency at the home. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: The registered manager and her deputy explained the homes admission procedure and two recent pre-admission assessments were viewed. The inspector was able to talk with two people and their relatives who have recently moved to live at the home. Either the registered manager and/or the deputy undertakes pre-admission assessments on all prospective people. The home has an assessment tool that covers all the relevant areas necessary for the home to decide if it is able to meet a prospective persons needs. The Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 10 registered manager was clear about the level of care needs the home can accommodate. The registered manager stated that ideally the person would visit the home prior to deciding to move in, however when this was not practicable relatives or representatives are invited to visit the home and view the available room. Six comment cards were received from people who live at the home. These all stated that they had received a contract and that they had received enough information about the home before they moved in. Eight comment cards were also received from relatives of people who live at the home who stated they had received enough information about the home. The inspector was able to meet the relatives of both people who had recently moved into the home who confirmed that they had received appropriate written information about the home and were aware of the terms and conditions of residency. Relatives stated that they had visited a number of homes before selecting Brookvale Lawn having been impressed by the service on offer. The inspector spoke with both people who had moved into the home shortly before the inspection visit. They and their visiting relatives confirmed that the manager had visited them to get information about their needs and had provided them with information about the home. Both had been offered the opportunity to visit the home before making a decision to move in. One had visited the home and during the visit decided to stay the other had not been able to visit due to mobility/transport needs however her relatives had visited the home. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. Medication is appropriately stored, however the Medication Administration Records contained a number of gaps so that it is not clear if medication has been administered or not. People are treated with respect. EVIDENCE: The inspector viewed four care plans for new and existing people. Care plans are individual and relevant to the needs of people. All care plans followed a similar format and are in an assessable format for care staff and people should they wish to see their care plans. Care plans contained life history information and detail as to how needs should be met including specific information about what people can do themselves and that which they require help with. Care plans were seen to be reviewed monthly or if needs changed significantly. Within all care plans were comprehensive individual moving and handling assessments, which clearly indicated how people should be supported with moving and handling. Also in care plans were risk assessments in relation to Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 12 falls, information about nutritional needs, and specific risk assessments relating to individual risk e.g. going out alone. Training records confirmed that staff have undertaken manual handling training. Manual handling equipment was seen during a tour of the home. The homes deputy manager is a manual handling trainer and assessor. The inspector was able to meet many of the people living at the home. They all stated that they felt very well cared for; others whose level of disability made conversation difficult appeared comfortable, relaxed and well cared for. The inspector spoke with five visitors’ who stated that they were very happy with the level of care their relative received. Comment cards were received from eight relatives, all stated that medical and care needs were always met. One added ‘they have good communication with GP’s and have got the balance of mums medication right’. No concerns about the level of care were raised in these comment cards. Comment cards were also received from six of the people who live at the home who stating that they always/usually receive the care and support they require. One adding ‘wonderful care and think myself very luck to be here’. People the inspector spoke with during her visit to the home made similar comments. People living at the home stated that they felt well looked after and that if they were ill the home would organise for a doctor to visit them. Comment cards from people living at the home stated that they always received the medical care they required. Comment cards were received from two GP’s who stated that the home seeks advice and acts upon it to improve and manage people’s health care needs and that individuals health care needs are always met by the home, one adding ‘excellent’ to the question are individuals health care needs met by the home. They also stated that they felt the staff had the necessary skills to meet people’s needs. Discussions with the manager during the inspection visit indicated that she knew how to contact external professionals and when this should be done. Records seen during the inspectors visit indicated that health professionals are consulted. The inspector undertook a tour of the home with the manager and was therefore able to meet some people who had chosen to remain in their bedrooms. Care staff stated that they felt they had enough time to meet people’s health and personal care needs. Discussions with and comment cards received from people confirmed that staff are available when required. Only senior staff who have undertaken additional training and been deemed competent administer medication in the home. All medication was seen to be stored in a secure locked facility. The home has complied with the requirement made following the previous inspection that the medications trolley should be secured to the wall of the room that it is stored in. This room is also used by Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 13 the hairdresser so may, on occasions be unlocked. The home uses a predispensed blister system where possible. The medication administration records were viewed and found to contain a number of gaps where it was not evident if medication had been administered or not. The registered manager stated that she would be discussing this with the staff concerned and commence a weekly audit of the medication administration records. Comment cards received from people confirmed that staff listen and act on what they say. People and relatives the inspectors spoke with confirmed that staff treat them with respect and that their privacy is maintained during personal care. During the inspectors visit staff were observed to treat people with respect, this was also confirmed by professional comment cards received. The GP’s confirmed in their comment cards that the home always respects individual’s privacy and dignity and responds to individuals’ different needs. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. People and relatives confirmed to the inspector that they are able to choose where in the home they spend their day, many were seen to spend time in the homes lounge with others remaining in their bedrooms. People confirmed to the inspector that they are given choice over their meals with options being chosen on a daily basis. Bedrooms seen contained personal items brought into the home. Care plans and assessments include information about life histories, leisure activities, catering and religious needs. People stated that they are able to get up and go to bed at times of their choosing. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 15 The home stated within the annual quality assurance assessment that a range of entertainments and activities are organised. The home has its own chapel in which monthly multi denominational services are held. The manager confirmed that should people have any specific religious or cultural needs these would be respected and met. On the day of the inspector’s unannounced visit the home had a visiting entertainer who was singing and playing a keyboard. The home also organises craft activities, tabletop games and bingo. One person mentioned that she liked gardening and the deputy manager stated that she would be able to help with the plants on the patio and that she hoped to grow tomatoes next year as an activity. Another person had helped with the flowers this year. The inspector was able to meet five visitors with comment cards from relatives stating that they are able to visit at any time and kept informed about issues affecting their relative. The home has a large lounge/dining room where many people choose to have their meals. People stated that the food is always good, ‘very good’, and choice provided. One relative commenting that his mother seemed to be really enjoying her food at the home. The inspector was present for the main lunchtime meal. The food appeared well presented and appetising. Drinks and snacks are also available throughout the day with people confirming this as well as the inspector observing people being given morning and afternoon hot drinks and biscuits. The need for special diets or supplements and eating utensils is recorded pre-admission. People were seen using adapted plates as stated on their care plans to maximise their independence. The environmental health department has recently inspected the home’s kitchens and two minor issues were raised related to risk assessments and paintwork on the windowsill were raised. Brookvale Lawn DS0000011776.V347209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: The homes complaints procedure is included in the service users guide provided to all prospective admissions or their relatives. Within the entrance hall is a notice providing further information as to what to do if a person or visitor has any concerns or complaints. The annual quality assurance assessment completed by the home prior to the inspection stated that ‘the home has an open culture which actively encourages discussion about concerns to be shared on a daily basis’. The manager stated that no complaints have been received. No complaints have been received about the service to the commission. People and relatives the inspector spoke with also stated that although they had no concerns or complaints they would feel able to raise any issues with staff or the manager. Comment cards from relatives stated that they knew how to make a complaint and the home had responded appropriately if any issues had been raised. This was also the view of the GP’s who completed Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 17 comment cards who stated ‘I have never raised any concerns with this home so far’. Care staff confirmed that they have attended safeguarding adults training as part of their induction and were clear as to the action they should take should they suspect that a person might have been abused. The manager has previously taken all the necessary action when she suspected (and then confirmed) that a safeguarding issue might be occurring. People living at the home stated they felt safe and would say to the manager if they had any concerns. The homes policies and procedures in respect of recruitment and people’s personal finances are included in the relevant sections of this report. Brookvale Lawn DS0000011776.V347209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe, well-maintained environment that meets their individual and collective needs. EVIDENCE: The manager showed the inspector round the home towards the start of the inspection visit. Following this the inspector was able to move around the home unaccompanied. The home was purpose built as a residential home approximately ten years ago. The tour of the building showed the home to be very clean and tidy throughout and there were no unpleasant odours. At the time of the visit the home was comfortably warm throughout. People confirmed that the home was warm and clean both to the inspector and in comment cards received. Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 19 The home is well maintained with the home having access to a maintenance person who was observed decorating a bedroom on the day of the inspectors visit. The home has a range of communal areas including, large lounge/dining room, small lounge on the second floor, library, hairdressing room, chapel, foyer and pleasant patio accessible from the lounge. All parts of the home are accessible via a passenger lift. The manager stated that the provider intends to redecorate and then replace carpets in the hallways and communal areas on the ground floor. The inspector saw a large number of new chairs, which had been delivered for use once the ground floor had been redecorated. Adequate bathing and toilet facilities are available with any necessary aids in place. The inspector viewed a number of bedrooms. All are equipped with an ensuite containing a WC and washbasin. One bedroom was in the process of being redecorated and the inspector saw the role of carpet that was to be laid once decoration had been completed. People stated they were happy with their bedrooms and these were seen to contain personal items including home entertainment equipment and items of furniture brought with them into the home. People confirmed, and the inspector observed that they could lock their bedroom doors and had a lockable facility within their rooms for valuables. The homes laundry was visited and is equipped with industrial machines capable of washing to disinfection standards. Members of staff spoken with confirmed they had received infection control training and had access to all the necessary equipment to prevent any risk of cross infection such as disposable gloves and aprons. Brookvale Lawn DS0000011776.V347209.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of care and ancillary staff that ensure that peoples needs are met. Staff receive the necessary training and good recruitment procedures are in place. EVIDENCE: All comment cards, from people who live at the home, relatives and professionals were positive about care staff. One person who lives at the home stated in the comment card ‘everybody is lovely’ and another ‘wonderful care and think myself very lucky to be here’. One relative commented ‘staff excellent’. One GP stated ‘very good, cooperative, care staff and management’. Discussions with people and their visitors during the visit to the home confirmed the above opinions. Duty rotas were seen during the visit to the home. Duty rotas stated that four (sometimes five) care staff (one senior), and a cook, kitchen assistant and cleaner, are provided in the morning; three care (one senior) and a cook in the afternoon/evening. Two awake care staff are provided at night. In addition the homes manager is available during weekdays. People and visitors stated that there are sufficient staff on duty. During the inspectors visit staff on duty corresponded to those on the duty rota and as stated by the manager. Care Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 21 staff stated that they generally have sufficient time to meet people’s needs and throughout the inspection care staff appeared to have time to meet people’s needs. The manager confirmed that an on call support is provided when the manager is at the home. The manager provided training and qualification information during the inspection and in the homes annual quality assurance assessment. The home has fifteen care staff of whom eight have an NVQ at least to level 2 and a further four staff are in the process of completing this qualification. On the day of the inspectors visit the four staff undertaking the NVQ had a meeting with their assessor and were able to complete another unit of the course. The registered manager identified in the homes annual quality assurance assessment that the home promotes staff training. The inspector saw a training matrix on the office wall that clearly identifies staff that have undertaken mandatory training and a list of outstanding training. There was also a list of staff to attend dementia awareness training. Care staff confirmed that they were not expected to undertake tasks outside their level of knowledge or skill. The home has a consistent staff team and has not recruited any new staff since the previous inspection. The home has joined the Chinese nurse project organised by Southampton Council and the allocated nurse has recently joined the homes staff team. Discussions with the manger indicated that she was fully aware of the necessary pre-employment checks that need to be undertaken in order to ensure that unsuitable people are not employed at the home. The manager explained the homes induction procedure that incorporates the skills for care common induction standards and showed the inspector the induction booklet in use at the home for care staff. Staff files contained evidence of induction. Brookvale Lawn DS0000011776.V347209.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, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. Records are generally well maintained and stored securely. The health, safety and welfare of people and staff are promoted. EVIDENCE: The home is managed by the registered manager who is supported by an experienced deputy manager and senior staff. Both the manager and deputy stated they have recently completed the Registered Managers Award and have Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 23 the necessary care qualification NVQ level 4. The manager has managed Brookvale Lawn for in excess of seven years. The inspector established through the course of the inspection, through observation and discussion that the manager and deputy manager work well as a team, share responsibilities and have an open door and inclusive approach to staff, visitors and people who live at the home. Care staff, visitors and people who live at the home stated that they felt able to approach the manager should they have any issues or concerns. The home undertakes formal quality assurance work and the inspector was shown surveys completed by people who live at the home and their relatives. The manager stated that she has started to evaluate the survey responses and discussed with the inspector how they would present the results of the surveys. The inspector viewed some of the completed surveys and these were positive about the home. The provider undertakes visits to the home and provides the manager with a report (Regulation 26 reports) following these visits. The manager stated that the provider is committed to ensuring the service provided to people living at the home is of a high standard. The home does not does not act as appointee for anyone. The manager holds small amounts of personal money for some people in the homes safe. The previous report identified that appropriate records are fully maintained for people’s money held by the manager. People living at the home confirmed that they have a lockable facility in their bedrooms and that bedroom doors can be locked. There were no previous issues re staff supervision therefore this non-core standard was not assessed. Care staff who completed comment cards stated that they felt supported. Various records were viewed during the inspectors visit with access only available to people who should have access. With the exception of the medication administration records discussed in an earlier section of this report records were well maintained. During the inspectors visit there were no concerns in respect of health and safety identified. Accident records were viewed and indicated that appropriate action is taken by staff following any accidents by people living at the home. The inspector also viewed the record of the weekly checks of the homes fire detection and management systems and these were in order. The home is well maintained and clean, with staff having relevant training to meet people’s needs. Brookvale Lawn DS0000011776.V347209.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 X 3 3 Brookvale Lawn DS0000011776.V347209.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. 1. Standard OP9 Regulation Reg 13 (2) Requirement The registered manager must ensure that the Medication Administration Records are fully completed with no gaps left. Timescale for action 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Brookvale Lawn DS0000011776.V347209.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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