Care Home: Brownhill Lodge

Similar services:

• Ashlong House
• Henry Nihill House
• Birchwood
• The Infirmary
• Orchard House Nursing Home
• St Josephs Rest Home
• Red Court Nursing Home
• Spinney (The)

What the care home does well People living at the home, relatives and significant others were overall very positive about the home, the staff and the support they received. One person said regarding the home `Its beautiful and clean` and in respect to staff ` They are all very nice here`. Another person said ` It`s a very good home, I am happy here` and regarding staff ` They are very understanding and polite`. Relatives/significant others` comments included `I am really impressed with what actually happens`, `Everything`s nice there. I have never had any problems with the home`, `It`s not too regimented, if they want to get up late` Peoples` health care needs are addressed well by the home. Contact with family and friends is supported by staff at the home and visitors are welcome at any time. Where possible people are encouraged to take control of their own lives for example manage their own finances and to bring in with them their personal belongings. Overall, meals are varied, nutritious and a choice is provided. Individuals are encouraged to raise any concerns/ complaints about the home and they are also protected by the home having comprehensive adult protection procedures in place and staff that are trained in adult abuse so it can be quickly identified and they know what action to take if required. The home is homely, generally well maintained and is clean and hygienic. Care staff are supported to achieve relevant qualifications and to undertake regular training to be able to meet the needs of those living at the home. The home is well managed.The views and feedback from people living at the home and relatives about the running of the home are regularly sought through meetings and surveys to make sure it is run in their best interests. What has improved since the last inspection? All individuals had a completed care plan that had addressed health, personal and social care needs and these had been reviewed on a regular basis. The home had obtained the necessary equipment to make sure everybody`s weight was taken monthly as part of monitoring their health. There were improvements in the opportunities provided to individuals to partake in different activities inside and outside the home. The home had looked at ways of making sure that staff could support individuals` personal choices in respect to daily routines more flexibly. CARE HOMES FOR OLDER PEOPLE Brownhill Lodge 334 Brownhill Road Catford London SE6 1AY Lead Inspector Ornella Cavuoto Key Unannounced Inspection 09:30 16 & 28th April 2008 th 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 Brownhill Lodge DS0000025613.V361800.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. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brownhill Lodge Address 334 Brownhill Road Catford London SE6 1AY 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) 020 8698 4978 tom_erman@hotmail.com DSRE Services Limited Helen McNally Care Home 21 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (21), Physical disability (1) of places Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. This home is registered for 21 persons of whom up to 21 can be elderly 1 person, aged 55 years or above, suffering from a mental health disorder up to 10 elderly persons can have dementia up to 4 elderly persons can have a physical disability 1 person, aged 55 years or above, with a physical disability Date of last inspection 24th April 2007 Brief Description of the Service: Brownhill Lodge is a large detached house in Catford, South East London. There are good local public transport links. The home is situated on the South Circular Road. It is approximately 10 minutes walk from a parade of local shops and a short drive from Catford town centre, which has some larger shops. It is registered to provide 24-hour care for 21 older people 10 of whom can have dementia. The aim of the home is to provide high quality residential care and support services in a homely and caring environment in which residents can be persuaded and will be encouraged to determine the pattern of their lives. The home has one double bedroom that used to be shared by two service users but is now used as a single room and the remaining service users each have a single bedroom. The home consists of a ground floor and two other floors, which are serviced by an accessible lift. There are no en-suite facilities but there are three bathrooms and seven toilets. One bathroom on the ground floor has been has converted to become a shower room that is accessible to wheelchair users. There are links with local health services for on-going advice and follow-up visits. Most referrals are drawn from Lewisham Social Services. Staff are experienced and are well trained. Information about the home is not made directly available to prospective residents but they themselves or their relatives or a representative on their behalf are always invited to visit the home prior to admission and there is information available that is kept in the entrance hallway. Reports written by CSCI are also kept in the hallway of the home. Monthly fees charged currently range from £440-£520. Additional charges may be made for hairdressing services, toiletries, magazines, newspapers and an escort if required. This information was provided to CSCI April 2007. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection. The majority of the inspection took place over one day. However, following the inspection time was spent contacting relatives by telephone to seek their views about the home. Four relatives/significant others in total were spoken to. The registered manager was present for the duration of the inspection and was helpful in facilitating the inspection process. Five people living at the home were spoken to. Other inspection methods used included looking at records and a tour of the premises was undertaken. Finally, an Annual Quality Assurance Assessment (AQAA) was sent to the home to complete prior to the inspection. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also provides some numerical information about the service. This will be referred to within the report. What the service does well: People living at the home, relatives and significant others were overall very positive about the home, the staff and the support they received. One person said regarding the home ‘Its beautiful and clean’ and in respect to staff ‘ They are all very nice here’. Another person said ‘ It’s a very good home, I am happy here’ and regarding staff ‘ They are very understanding and polite’. Relatives/significant others’ comments included ‘I am really impressed with what actually happens’, ‘Everything’s nice there. I have never had any problems with the home’, ‘It’s not too regimented, if they want to get up late’ Peoples’ health care needs are addressed well by the home. Contact with family and friends is supported by staff at the home and visitors are welcome at any time. Where possible people are encouraged to take control of their own lives for example manage their own finances and to bring in with them their personal belongings. Overall, meals are varied, nutritious and a choice is provided. Individuals are encouraged to raise any concerns/ complaints about the home and they are also protected by the home having comprehensive adult protection procedures in place and staff that are trained in adult abuse so it can be quickly identified and they know what action to take if required. The home is homely, generally well maintained and is clean and hygienic. Care staff are supported to achieve relevant qualifications and to undertake regular training to be able to meet the needs of those living at the home. The home is well managed. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 6 The views and feedback from people living at the home and relatives about the running of the home are regularly sought through meetings and surveys to make sure it is run in their best interests. 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. Brownhill Lodge DS0000025613.V361800.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 Brownhill Lodge DS0000025613.V361800.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): 3 Standard 6 is not applicable. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all individuals that had been admitted to the home had their needs fully assessed prior to moving into the home. EVIDENCE: The personal files of five people living at the home were looked at as part of the inspection. Three of the files belonged to individuals who had been admitted since the last inspection. It was noted for one of them that they had been moved in before a full needs assessment from the referrer was obtained. For another person admitted on a respite basis a needs assessment was obtained the same day they moved in. The registered manager reported that this was sent to the home prior to their admission. It is important that full needs assessments are obtained in advance of admission so that peoples’ presenting needs can be fully assessed and the home can ensure that they will be able to address all their needs (See Requirements). Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 9 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans drawn up with individuals covered all required needs and had been generally reviewed on a regular basis. Peoples’ health care needs had been met by the home. Medication policies and procedures had generally been adhered to by staff but some measures to safely support individuals to selfadminister their medication needs to be taken by the home. Peoples’ privacy was maintained and staff treated them respectfully. EVIDENCE: The last two inspections had identified concerns about care plans and at the last inspection it was found that not all individuals had a care plan that was fully completed to ensure all individual health, personal and social care needs had been addressed. Also, monthly reviews of care plans and fall risk assessments had not been carried out. At this inspection, five care plans were looked at and improvements had been made. The home uses the standex format for care plans. All had a completed care plan based on needs assessments obtained from referrers and personal, health and social care needs had been addressed in sufficient detail. Care plans had been signed by people living at the home. Also, their relatives and significant others of Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 10 individuals that were spoken to stated they had been involved in the care planning process. Care plans had been reviewed and were reflective of changing needs although it was noted that the ‘long term assessment of need’ had been reviewed at different intervals ranging from two –six months although where specific needs had been addressed in the ‘short term’ care plan these had been reviewed monthly. It is recommended that both parts of the care plan be reviewed on a monthly basis. Fall risk assessments were in place for all individuals and these had also addressed any individual risks that were identified. Apart from a gap of a month these had been reviewed regularly (See Recommendations). At the last inspection it was identified that although peoples’ health needs had generally been well addressed that not all of them had had their weight monitored monthly as specified by National Minimum Standards (NMS) and this was due to the home not having sit down weighing scales. At this inspection this had been addressed with the home having purchased the equipment required and all individuals whose records were checked had their weight taken on a monthly basis. In addition, it was evident from their care plans and from notes contained within the files of visits from a range of health care professionals including GPs, district nurses, opticians, dentist, chiropodists and mental health professionals that their health care needs had been met. In respect to medication, a sample of medication records was checked and apart from one minor error all were found to be accurate. Subject to a previous requirement, that it should be ensured that the quantity/stock of tablets including any balance brought forward is written on the medication record this had been addressed at this inspection. Stocks of medication that were checked corresponded with medication that had been administered. However, concerns were raised that one of the people living at the home who was staying on a respite basis had not been encouraged to take responsibility for their own medication. The home had not taken action to complete a self- administration risk assessment and it was also identified that the medication policy did not address self -administration and procedures to be followed by staff. Furthermore, it was identified that another person living at the home did selfadminister their insulin but a self- administration risk assessment had also not been completed with them prior to this being put in place (See Requirements). During the inspection staffs’ interaction with people was observed as being respectful. Relatives spoken to and also people living at the home also stated staff were polite and friendly and they always knock before entering their room ensuring their privacy was upheld. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 11 Brownhill Lodge DS0000025613.V361800.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individuals had been provided with opportunities for social stimulation and interaction. The home had supported people to maintain contact with family and friends and to exercise their rights of choice and control. Meals provided have been balanced and nutritious and enjoyed by people living at the home. EVIDENCE: At the last inspection it was identified that opportunities provided to people living at the home for social interaction and stimulation were overall quite limited and although records indicated some activities had taken place it had mainly been noted by staff that people spent their time watching television. At this inspection it was evident from records and speaking to relatives and individuals at the home that improvements had been made in respect to activities. Individual activity logs that had been maintained indicated that people had been regularly involved in a range of different activities including sing- a- longs, quizzes, reminiscence, doing arts and crafts, exercises amongst others. There was also evidence from records that individuals had been taken shopping and there had been trips to the local theatre and to Eltham Palace. The registered manager reported that further trips out were to be planned. In addition, the home has outside entertainers coming into the home. On the day of the inspection people spent time listening to music and one of the staff tried Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 13 to engage them to do some art and craft, making bracelets with beads. One of the relatives spoken to commented ‘There is an awful lot of activities’. One individual spoken to said ‘ Staff do play games with us’. In respect to people living at the home being supported to exercise choice around routines of daily living concerns were raised at the last inspection that although personal preferences had been specified within care plans that some individuals had been placed in their bedclothes ready for bed in the afternoon. Staff spoken to at the time stated this was necessary to assist the night staff due the number of people requiring assistance with personal care. This indicated that staffing levels were not sufficient to meet their needs and as a consequence the home’s routines were inflexible. Yet, staffing levels were assessed as adequate. At this inspection there was no evidence that this practice was still occurring and the registered manager reported that staffing levels had been looked at since the last inspection and some measures were taken to ensure extra staff were on duty during the busy periods of the day specifically in the morning and in the evening (See Standard 27 for further details). Relatives spoken to following the inspection confirmed that people living at the home are supported to maintain contact with family and friends. All stated that they regularly visited the home and were made to feel welcome by staff. One relative said ‘ I go there at different times and there has never been a problem’. They also reported that the home would contact them to inform them of any changes in care. There was also evidence that people had links with the local community. A representative from the local Catholic Church visits the home. In addition, the registered manager reported that two individuals attend services at local churches of their own religions. One person at the home visits a day centre locally that meets their specific cultural needs. There was evidence that people living at the home were able to exercise choice and control, for example two individuals managed their own finances and people were able to bring their personal belongings when they moved in. This was evident from bedrooms that were seen. Meetings had been held two monthly up till December 2007 in which people at the home had been given an opportunity to discuss and make decisions on various issues relating to the home. However, it is recommended these be held on a regular basis (See Recommendations). The home has a four-week rolling menu that offers a choice of foods. Records had also been kept where meals had been provided that differed from the menu. At previous inspections it was identified that there was some repetition but from the records maintained it was evident that meals were sufficiently varied. On the day of the inspection a lunch- time was observed and the meal served was as specified on the menu. It was relaxed and unhurried and people appeared to enjoy the food. Individuals that were spoken to confirmed this. One person commented ‘I do like the food’. Finally, those individuals that Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 14 required assistance to eat were supported in an appropriate and respectful manner by staff. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints policy and both relatives and people living at the home were aware about the process. People have been protected from abuse. EVIDENCE: The home’s complaint policy is comprehensive. Relatives and significant others of individuals living at the home spoken to were all aware of the home’s complaints policy and stated they would feel comfortable bringing their concerns to the manager or to staff. A significant other of one individual stated that the manager was quite responsive in dealing with concerns that they had raised whilst a relative stated ‘I know who to contact if I need to’. People spoken to all stated that they did not have any complaints about the home but that they would speak to staff or the manager if they did. The home’s complaint log was checked and there was evidence that three complaints had been recorded since the last inspection. Two of these related to medication issues; one in which a relative found some tablets that had not been taken in a drawer and the other related to a relative’s concerns about a delay in the home obtaining a prescribed medication. Both were substantiated. The third complaint made by a relative related to glasses being mislaid. Appropriate action was taken in respect to all the complaints made. The home’s adult protection policy and procedure is comprehensive. All the care staff had completed training in adult abuse apart from three staff that that had been recruited to work at the home within the last few months. There Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 16 was evidence that it had been arranged for these staff to do the training to be provided in-house on 03/06/08. In addition, it was identified that ancillary staff had not completed the training. It is advised they also undertake the course. Finally, although the registered manager did have some knowledge of action to take in respect to adult protection issues and had attended a course previously it is recommended they consider attending a course that relates specifically to their responsibilities as a manager in relation to protection of vulnerable adults. There has not been any adult protection investigations carried out since the last inspection (See Recommendations). Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 17 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, 21,24 & 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical environment of the home meets the specific needs of the people who live there with safe and comfortable communal facilities. There are sufficient toilet and washing facilities. Individuals’ bedrooms are suitably personalised and the home was clean and hygienic. EVIDENCE: The home is suitable for its stated purpose and it is generally well maintained, safe and homely. Some of the bedrooms had been decorated and the registered manager also reported that some of the furnishings were to be renewed, for example new curtains were to be bought for all communal areas and new flooring was to be placed in the dining room. All parts of the home are accessible to people living at the home with a passenger lift being in situ and the home can accommodate wheelchair users. The registered manager had also put in place signage on doors of the rooms to help orientate people with dementia. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 18 The home has adequate communal facilities. There is a separate dining area, a lounge and a conservatory area that leads out to a small, well - maintained garden. The home has sufficient bathrooms and toilets. There is a shower on the ground floor specifically for those individuals who may be wheel chair users and also for those with mobility problems. Subject to a previous requirement that a toilet leaking on the first floor should be fixed was addressed at this inspection. Also, at this inspection the home had started work on updating the ground floor bathroom with a new bath having been purchased that was identified at the last inspection as in need of being replaced. All the bedrooms were inspected and they were suitably personalised. The home was generally clean and hygienic on the day of the inspection and there were no offensive odours. The home has laundry facilities sited away from the preparation of food. Brownhill Lodge DS0000025613.V361800.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Measures had been taken by the home to ensure staffing levels were adequate to be able to flexibly and fully meet the needs of people that live there. The home had supported staff to undertake relevant qualifications and other regular training courses required under National Minimum Standards (NMS). The home’s recruitment practices did not fully protect people living at the home. EVIDENCE: As mentioned in respect to Standard 12 concerns were raised at the last inspection about people being in their bedclothes when it was still only afternoon. Although staffing levels were deemed to be sufficient it was recommended that a review of staffing arrangements be carried out to ensure that peoples’ support needs were fully and flexibly met. At this inspection the registered manager reported that following the last inspection an additional staff member had been placed on the rota for part of the morning shift between 7am –9am and also for part of the evening shift between 7pm –9pm to ensure peoples’ needs were able to be fully met at these times i.e. when they were getting up and getting ready to go to bed. The rota was checked and was found to reflect these changes. It was also accurate in respect to those staff working at the home on the day of the inspection. The home has twenty care staff working at the home; eleven full- time and nine part- time. The registered manager reported that all the staff apart from Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 20 two had completed a National Vocational Qualification (NVQ) Level 2. This meets the required target specified within NMS that 50 of staff should have achieved a relevant qualification. In respect to recruitment, three staff files were checked belonging to staff that had started working at the home since the last inspection. Generally, the process was robust. There was evidence contained in the files that all the required checks and information had been obtained including two references, appropriate identification and an Enhanced Criminal Bureau check (ECRB). In addition, there were records that two staff had been involved in the interviewing process in line with equal opportunities. However, it was noted that all three staff members had initially started working at the home after a check against the Protection of Vulnerable Adults (POVA) list, which includes the names of persons deemed unsuitable to work with vulnerable adults had been obtained. Although this is permissible in the interim period that the ECRB checks are received on the condition staff are supervised this measure should only be used in an emergency situation and not as a matter of course when recruiting staff. Furthermore, it was evident from application forms that there were gaps in employment in respect to all three of the staff but these had not been addressed with reasons provided noted within their files. This needs to be addressed (See Requirements). The home had introduced an induction work booklet to be completed with new staff that meets with Skills for Care specifications since the last inspection. There was evidence in one of the staff files checked that they had completed this. In addition, there was evidence that two of the three staff whose files were checked had completed an initial basic induction. It is advised a record of this is maintained for all staff within their personnel file. A training plan had been drawn up that detailed the dates of courses covering all mandatory handling topics including manual handling, fire safety, food hygiene, infection control amongst others to be attended by staff. Other staff had been supported to undertake specific training to be able to meet the needs of people living at the home more effectively, for example two care staff were in the process of completing a long distant learning course in respect to dementia. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 21 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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was managed well and run in the best interest of people living there. People’s finances have been safeguarded. The health and safety of people living at the home and staff had been promoted and protected. EVIDENCE: The registered manager has been in post for approximately a year. They worked previously at the home as part of the care staff team and so had some familiarity with the running of the home. They also had experience working in the care field working with young people previously and therefore did have relevant experience and skills to be able to manage the home effectively. It was evident through the inspection process that the home was in the main well run. Furthermore, to increase and update their knowledge around the needs of people with dementia the registered manager had started a long distantBrownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 22 learning course and they also reported that they were to commence the Registered Manager’s Award (RMA) in September 2008. At the last inspection there was evidence that the home had carried out customer satisfaction surveys with people living at he home, relatives and professionals, the results had been compiled in a report and also fed back to service users but an action/development plan detailing aims and outcomes for service users resulting from the surveys had not been drawn up. However, at this inspection following surveys having been completed an action/development plan had been completed that was seen. The home’s AQAA submitted to CSCI prior to the inspection had been satisfactorily completed. The home had robust systems in place for the management of finances belonging to people that live there. Individual records detailing all transactions and receipts had been kept. A sample of records was checked and were all found to be accurate. The finances are audited on a fortnightly basis. There was evidence that the health and safety of people living at the home and staff had been protected with up to date maintenance certificates in place for electrical appliances (PAT) and electrical wiring, gas safety, fire equipment and for hoists and the lift. A fire risk assessment had been completed and monthly health and safety checks in respect to the home had been carried out. Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X 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 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement The registered manager must ensure that a full needs assessment is obtained from the referrer prior to people being admitted to the home to make sure that all their presenting needs can be fully met and the home is a suitable placement. The registered manager must ensure that self -administration risk – assessments are carried out with people to determine whether they would be able to take responsibility for their own medication. The registered manager must ensure that the home’s medication policy includes procedures on selfadministration of medication as part of maintaining peoples’ health, safety and welfare. The registered manager should ensure that the POVA First check is only used in emergency situations and not to start staff as a matter of course without a CRB check to fully protect people living at the home from abuse. DS0000025613.V361800.R01.S.doc Timescale for action 31/10/08 2. OP9 13 (2) 31/10/08 3. OP9 13(2) 31/10/08 4. OP29 13(6) 31/10/08 Brownhill Lodge Version 5.2 Page 25 5. OP29 19 The registered manager must ensure that where there are gaps in employment these are fully accounted for and reasons noted in their personnel files to ensure recruitment practices are fully protecting people living at the home. 31/10/08 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 OP1 Good Practice Recommendations The registered manager should consider providing information to people who may move into the home and /or their relatives when they visit so they can make a fully informed decision about the home and that it is suitable to meet their needs. (Previous recommendation not checked) The registered manager should try to make sure that both the ‘long term assessment of need’ and the ‘short term’ care plan are reviewed monthly. The registered manager should try to make sure that meetings involving people living at the home are held on a consistent and regular basis. The registered manager should try to make sure that ancillary staff working at the home attends adult protection training. The registered manager should consider attending an adult protection course that directly relates to their responsibilities as a manager in respect to adult protection. 2. 3. 4. 5. OP7 OP14 OP18 OP18 Brownhill Lodge DS0000025613.V361800.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Brownhill Lodge DS0000025613.V361800.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!