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Inspection report

Date of Inspection: 10 November 2011
Date of Publication: 14 December 2011
Inspection Report published 14 December 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

People are being given the opportunity to pass on their views about the home. Systems are in place, which help to ensure that the facilities are safe for people. The provider is identifying ways in which the service can develop and improve, although the monitoring of the home has not been effective in improving the standard of the care plans.

Overall, we found that Brendoncare Froxfield was meeting this essential but, to maintain this, we have suggested that an improvement is made.

User experience

People told us they would be able to talk to one of the staff team if they had any concerns or they wanted to pass on their views. Comments could also be passed on anonymously using a suggestions box that was in the front hall of the home.

There were also more formal arrangements in place for gaining feedback and monitoring the quality of the service. Meetings were being held every six months to gain feedback from the people who used the service and from their relatives. Annual surveys were also being used; the home’s manager told us that this year’s surveys had been returned to the provider’s head office where they were currently being analysed.

Staff members had the opportunity to pass on their views using a staff forum which met every two months. This involved staff from all the provider’s homes and two staff from Brendancare Froxfield attended the meetings. When we met with staff they told us about the developments they had seen in the home, such as the purchase of new electric beds and improvements in how risks were being managed.

We were told that there were plans to upgrade some items of equipment. A staff member said that the hoists in the home were working as they should, but a more modern type of hoist would be beneficial. We saw labels with dates on the hoists and on the portable electrical appliances, confirming that they had been checked for their safety.

Checks of the equipment and facilities were also being undertaken on an in-house basis. A maintenance person told us that they carried out regular checks of bedrails, wheelchairs and the home environment as a whole. They said they also made weekly tests of the fire alarm system to ensure it was working correctly. We were told that staff reported any repairs and maintenance issues that they found during the course of their work.

Other evidence

We were shown a copy of the provider’s business plan for 2012 – 2013, which identified some key developments and areas for improvement. Dementia training was reported to be a priority, as was refurbishment of some areas of the home. It was stated in the plan that staffing levels would be maintained to ensure that they matched dependency levels.

A senior manager from the Brendoncare Foundation visited the home each month, for monitoring purposes and to check on compliance with the standards. They wrote a report of their findings.

At a previous inspection of the home, there had been a discussion about how these visits could be improved. This had included a more detailed review of care plans. This was in order to identify the variability in care planning that was found at the time and to ensure that action was taken to improve the quality of the care plans. The monthly report for October 2011 did not refer to shortcomings in care planning and assessments and there was no action plan for making the improvements that were needed. As reported under outcome 4, there were some significant shortcomings in the standard of the care plans.