Inspection on 07/04/08 for Heathbrook House

This is the latest available inspection report for this service, carried out on 7th April 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Heathbrook House 223 - 229 Worcester Road Stoke Heath Bromsgrove Worcester B61 7JA Lead Inspector Chris Potter Key Unannounced Inspection 09:30 7th April 2008 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 Heathbrook House DS0000070913.V361618.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. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heathbrook House Address 223 - 229 Worcester Road Stoke Heath Bromsgrove Worcester B61 7JA 01527 882146 01527 879928 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) BUPA Care Services Limited Laura Taylor Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Heathbrook House DS0000070913.V361618.R01.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 with nursing (Code N) to service users of the following gender, Either, Whose primary care needs on admission to the home are within the following categories: Older People (OP) 45 The maximum number of service users to be accommodated is 45. 2. Date of last inspection Not applicable Brief Description of the Service: Heathbrook House is a new purpose built nursing home that opened in November 2007. It is located in a residential area of Stoke Heath, close to Bromsgrove town centre. It is on a bus route and within walking distance of the local shops. Heathbrook House provides nursing care services for older people, who are accommodated on two floors of the home. The home provides 45 single bedrooms each fitted with an en suite with a hand basin, toilet and shower. Access to each floor is gained via a central passenger lift. The home provides two large lounge / dinning areas, quiet lounges, conservatory, library and hair salon. Information regarding the home can be obtained from the Statement of Purpose and the Service User’s Guide, which are available in the reception area of the home. More information can be obtained from the intranet www.bupacarehomes.co.uk, and copies of the inspection report. Heathbrook House is part of the BUPA Care Homes group, which is a large national organisation. The registered manager is Laura Taylor who is first level registered nurse with many years experience in care home management. The fees for Heathbrook House vary for up to date information please contact the home direct. Any additional charges are laid out in the homes terms and conditions. Heathbrook House DS0000070913.V361618.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 the service experience good quality outcomes. The focus of inspections undertaken by the CSCI is upon outcomes for people and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practise and focuses on aspects of service provision that need further development. This was the home’s first key unannounced inspection since they opened in November 2007. The key inspection is where we look at a wide range of areas. The inspection was carried out over a full day on the 7th of April 2008. The registered manager was available throughout the inspection. To help us plan for the inspection we looked at pre – inspection information requested earlier, this included the Annual Quality Assurance Assessment (AQAA). A range of evidence was used to make judgements about the service. This includes: information from the manager, staff, residents, relatives, feedback from surveys, tour of the premises, records and registers, and observation of care experienced by people using the service. Feedback received during the inspection from residents and relatives who were spoken to included: “The staff are fantastic” “Always a pleasant atmosphere” “The care is “superb” “All staff communicate well with us and keep us informed about any changes” “all staff are friendly, polite and respectful” “Mom is very happy” “They are very good with residents suffering with dementia” “They are excellent” “The food is good” “The food is excellent and I have never had a bad meal” “I like my room it is very nice, light and bright” “No odours the home is always fresh and clean” “The heating is effective we have a thermostat to control the temperature of my room” “Good laundry service, fast turnaround” We would like to thank the manager, staff, residents and relatives for their assistance and hospitality. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations were identified as a result of this inspection the home either met or exceeded the standards with the exception of the number of carers with an NVQ level two qualification. The home provided information in their AQAA about how they intend to further develop the home and service provision. The AQAA gave an accurate reflection Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 7 about the home. It confirmed the services plans to further develop their service this included over the next 12 months: • • • • Staff supervision for the nurses. Implement residents and relatives meetings as the occupancy levels increase. NVQ level two qualifications for the carers. Further develop the quality assurance process 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. Heathbrook House DS0000070913.V361618.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 Heathbrook House DS0000070913.V361618.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): We looked at standards 1 and 3 standard 6 is not applicable the home does not provide intermediate care Quality in this outcome area is good. The pre-admission assessment provides relevant information, to ensure that the home is able to meet the identified needs of residents as well as an appropriate introduction to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective residents have access to a range of information about the service including a Service User Guide, so that people know what they can expect and are aware of the services being provided. The information about the home is available in the reception area along with, various brochures and leaflets about BUPA and their services. A copy of the Service User’s Guide was also available in the resident’s bedrooms. BUPA also have a good web site for more information about the organisation and their services. The certificate of Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 10 registration and other certificates were displayed in the reception area of the home. Prospective residents and or relatives are encouraged to visit the home to assist them with their choice. The receptionist and administrator were polite and welcomed visitors into the home. All visitors are requested to sign the visitor’s book on arrival for health and safety reasons. Residents and Relatives spoken to said they received a range of information about the services provided and were fully informed. Comments received from residents and relatives included: “chose this one because we were so impressed when we looked around the home. The attitude of the staff was very professional and the care is superb.” “I can’t believe how he has settled and feel this is because of the care and attention shown by all the staff.” “ It is a lovely atmosphere, Dad came in for respite and decided to stay the staff are fantastic, food is excellent no problems with the Laundry very pleased with the hairdressing services.” “The home is excellent, the staff answer the buzzers promptly. My husband was admitted for a months trial following his discharge from hospital, and has settled really well.” Two resident’s care records were reviewed at the inspection. These included a copy of the pre – admission assessment that is completed by the registered manager. The assessment takes into account the individual needs, concerns and anxieties of the prospective resident and their families about moving into a home. This ensures that the home can meet the health and personal care needs of the person. The pre – admission assessment then forms part of the residents care record. On admission to the home the resident is allocated a named nurse and carer to assist them settling into the home. The assessment also records the person’s preference for female or male carers for personal care, which is respected. Heathbrook House DS0000070913.V361618.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and respect are put into place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two of the residents care records were examined during the inspection. The care plan had been developed from the assessment completed prior to admission. The care plans were individualised for the residents and recorded the resident’s preferences about their care delivery and their perception of needs. Care plans contained sufficient information to assist the nurse’s and carers to meet the resident’s health, physical and social care needs. The care assessment included information to ensure that equality and diversity was covered, this included male or female carers, religious needs and dietary choices. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 12 A good range of pressure relieving equipment was observed in use during the inspection. All beds are specialist ones which provide assistance with preventing skin pressure damage. The home is well provided with specialist equipment to assist residents to maintain their independence with assistance. Whilst going round the home the residents appeared comfortable with the staff and a pleasant atmosphere was evident. Comments received from residents and relatives were most complimentary about the standards of care and the professionalism of the staff. observed all grades of staff being polite and respectful towards the residents. Comments received included: “the staff are fantastic” “Always a pleasant atmosphere” “The care is “superb” “All staff communicate well with us and keep us informed about any changes” “all staff are friendly, polite and respectful” “Mom is very happy” “They are very good with residents suffering with dementia” “They are excellent” The home has a nominated General Practitioner (GP) for the home, but residents have the choice of maintaining their own GP. A record is maintained of all GP visits in the individuals care record and any other specialist they have seen. The home has a well-organised medication procedure, and the medication for the residents being case tracked was audited. This showed that the correct amount of prescribed medication had been administered. The correct amount of medication remained, and no gaps were evident on the residents’ medication administration record. The manager also completes a monthly audit and the supplying pharmacy completes audits for medication compliance. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14 and 15 Quality in this outcome area is good The home offers a limited range of activities, which are individually tailored to meet the varying, needs of the residents. Relatives are free to visit at any time. A varied nutritional diet ensures nutritional needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the home was accommodating 12 residents. The manager advised that they have had difficulties in recruiting a suitable activities organiser. A carer is currently overseeing activities in the home with great enthusiasm. On the day of the inspection the home was preparing for a visit from a wartime drama group. The catering staff had even prepared a menu from the war days using dried eggs, and fish paste sandwiches etc. the event was well supported with relatives and friends, and everyone appeared to enjoy reminisce about their own experiences. All the bedrooms are equipped with televisions and freeveiw, and a radio. A telephone is fitted to all rooms and the resident is billed at the end of the Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 14 month for any calls they make. All bedrooms are fitted locks and a locking drawer for the resident’s personal items. Satellite channels are fitted to the large televisions in the lounges. A small Library has been developed with a good range of books for residents who may wish to sit quietly. The residents have a choice of lounges, garden room and gardens to use. Other activities displayed for the coming week included, music group with instruments, poetry, board games and reminiscence groups. Religious services are arranged weekly for residents who chose to attend. The residents confirmed that they have a choice about how they spend their day, what time they get up and go to bed. Information is also included in the residents care plans for residents with more complex needs who are unable communicate their needs. Visitors are welcome to visit the home at any time and are able to order meals to join their relatives. The home provides a good varied menu for the residents. Which rotates every four weeks and seasonal changes are made. The catering staff uses a system, which records the residents diet and fluid intake on a daily basis. At lunch time the residents are given a choice of two main choices, the choices on the inspection day were steak in red wine or a tuna, other alternatives are available every day i.e. omelettes. Breakfasts – cereals and toast or a cooked breakfast if they wish 10.30 – 11.00 am refreshments 13.00 - Lunch, which is two courses 15.00 - afternoon tea with homemade cake. 17.00 - tea –The home provides a variety of food including soup, sandwiches, or a hot meal with a pudding after. On admission the residents are asked their likes and dislikes to assist the catering staff and the carers. The home also offers a night bite menu, which the carers can do when the kitchen is closed. A hostess is employed at the home from 10am until 3pm seven days a week, and they are responsible for drinks, meals, water jugs etc. They assist the residents with their menu choice for the next day. The chef serves the meal with the hostess. A recent audit completed for the food gave a 93 excellent score from the returned surveys. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 15 The staff were observed assisting the residents appropriately with their meals, hot and cold drinks being offered. Comments from relatives, residents and staff about the food included: “Impressed by the menu, good choice and freshly prepared food” “The food is good” “the food is excellent and I have never had a bad meal.” The manager is looking to start a relatives group and regular newsletter as the occupancy levels increase. Heathbrook House DS0000070913.V361618.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): Standards 16 and 18 Quality in this outcome area is good. Procedures in the home ensure that any complaints or allegations of suspected abuse are taken seriously and are managed appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home registered in November 2007, and no complaints have been received by the CSCI since that time. The organisation has a good complaint’s system in place, which is easily for people using the process. A copy of the complaint’s procedure is displayed around the home and all residents and relatives are provided with a copy of the procedure in the Service User’s Guide. Residents and relatives spoken with were aware of the procedure and who to talk to. A relative stated that an issue they raised was addressed quickly. The home maintains a record of any complaint raised; this includes the date of the complaint, name of the complainant, details of the complaint and the outcome. One complaint received by the home since November 2007 was about the length of time taken to answer the front door in the evening. The response was within the timescale and acknowledged that if staff were busy with residents there may at times be a delay. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 17 The home had received many compliments and these included: “to all the staff thank you for my care” and “All staff are outstanding.” All staff receive training to assist them in recognising potential abuse. The induction training also includes the basics about various types of abuse. All staff spoken with during the inspection was confident that they would have no hesitation in reporting any concerns to ensure that the residents were safe. An allegation about the conduct of a member of staff was referred appropriately by the home to the safeguarding team. The home have taken appropriate action and notified appropriate authorities including the Nursing, Midwifery Council, as it was in respect of a qualified nurse. Heathbrook House DS0000070913.V361618.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): Standards 19 and 26 Quality in this outcome area is excellent. The physical design and layout of the home enables people who use the environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Heathbrook house is a new purpose built home that opened in November 2007. It is situated in a residential area of Stoke Heath, close to Bromsgrove town centre. Heathbrook House has been designed specifically to meet the requirements of elderly residents with nursing needs. The home provides accommodation for 45 residents on two floors with a lift fitted to assist the residents to move around the home. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 19 The second floor can accommodate 23 residents in en suite bedrooms there is a lounge with seating area and dining area, a quiet lounge and a hair salon. The hair salon is well equipped and the hairdresser visits once a week. The ground floor can accommodate 22 residents in en suite bedrooms, a lounge and dining area, two quiet lounges and a conservatory. The home also benefits from an under floor heating system, which can be controlled for each individuals bedroom for the temperature of their choice. The home also provides attractive gardens for the residents to use when the weather permits. Positive comments about the homes environment and facilities were received from the residents, relatives and staff. Comments received included: “I like my room it is very nice, light and bright.” “no odours the home is always fresh and clean.” “The heating is effective we have a thermostat to control the temperature of our room.” “Good laundry service, fast turnaround.” On walking around the home it was observed that several residents have personalised their bedrooms to reflect their personality. The home was clean and tidy in all areas, this was commended. The home is light and spacious throughout with a high standard of decoration and furnishings throughout. Appropriate equipment and aids are available throughout the home to assist the residents to maintain their independence. A Maintenance person works full time and is very well organised, all records and registers requested were available and up to date. The maintenance person is also the fire trainer, and provides instruction for all staff. Fire records were well organised and up to date. The home has systems in place for the prevention of cross infection, and staff were aware of the infection control policies. Training is provided for all staff as part of their annual mandatory training update. Throughout the home hand gels are available for staff and visitors to use. Staff were observed wearing gloves and protective aprons appropriately. The Nurse Call system is a pager system, which the nurse and carer carries with them, and goes to the resident’s bedroom to silence the call. It is a quiet system, which does not disturb the residents. All staff spoken to confirmed that they were pleased with the homes accommodation and the layout was suitable for the residents being cared for. Heathbrook House DS0000070913.V361618.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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. Staff in the home are trained, skilled and available sufficient numbers to meet the needs of the residents. A rigorous staff recruitment procedure assists in further protecting the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas for the month were seen and showed nurses and carers rostered for the 24-hour day proportionate for the number of residents. The manager is supernumerary to the numbers. A qualified nurse was always on duty and was supported during the day and evening two carers and by one at night. In addition to the nursing and care staff the home employs a hostess person who works 0700 – 1500 seven days per week. Full time maintenance operative, receptionist, administrator, Domestic, laundry, and catering staff make up the homes staffing compliment. The home currently has a vacancy for an activities organiser and deputy manager. The home has only used agency staff to complement their own staff when the numbers increased for a short period. Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 21 Staff spoken to felt that the staffing levels were fine, and they could provide the care for the residents fully. Residents and relatives confirmed this and comments included; “respond promptly to the call bell” “with only two staff on nights you have to wait at times for the door to be opened” “the staff are very professional” The home has a good staff-training program in place; they have developed a training matrix, which is computerised. In addition each staff member has a training folder, which includes an induction, mandatory training, health and safety, food hygiene and risk assessments. Two staff are trained in moving and handling, senior infection control person, and fire trainer all working at the home. Staff confirmed they had attended the training and were aware of the policies and procedures. Comments from relatives and residents included: “all staff are excellent” “staff are fantastic” “attitude of staff professional” “very good with residents with dementia” Three staff files were reviewed at the inspection. The files showed that the home had followed their rigorous recruitment procedure. Appropriate safety checks had been completed prior to the staff member commencing. This further assists in safeguarding the residents. The home’s AQAA confirms that an NVQ level two qualification is to commence later in the year. Staff spoken with confirmed that they had received the training and felt that they had the competencies to meet the needs of the residents in the home. Heathbrook House DS0000070913.V361618.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): Standards 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. The management and administration of the home is based on openness and respect. There are effective quality assurance systems in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Laura Taylor is the registered manager for the home. The manager is a first level registered nurse who has managed care homes for many years. She has also completed the registered manager’s award, and an assessor’s qualification. (this assists with NVQ training) The manager confirmed that she likes to work the occasional shift to assist staff; it helps with knowing the residents, and monitoring the staff. The manager also works over the seven Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 23 days to meet the relatives and friends. Residents, relatives and staff spoken with confirmed that the manager is supportive and approachable for any queries. From observation the manager interacted well with all grades of staff, residents and their relatives. Both residents and relatives knew who she was. The manager confirmed that BUPA are very good at responding at any requests for additional items for the residents outside of the allocated budget. At the moment the residents’ monies are being managed by themselves or on their behalf by relatives. The home is in the process of setting up a system for small amounts of money to be deposited with them for hairdressing etc, but this is taking some time with the Bank. A staff supervision system has been commenced, for the carers and the heads of departments. The manager confirmed that the nurse’s supervision would recommence when a deputy manager has been appointed. The supervision records are detailed and show the process of review. The manager has implemented an auditing process as part of their quality monitoring process. This includes care plans, medication, accidents, health and safety, audits in place. In addition catering and housekeeping audits are completed. Results of the audits were available and concluded that the home is achieving good compliance. The area manager for BUPA also completes a monthly review and forwards a copy of this to CSCI. All staff receive regular mandatory heath and safety training that includes first aid, moving and handling and fire drills/ practices carried out at the home. This ensures safe working practices and maintains the health and safety of residents. The AQAA was completed and gave an accurate reflection of the home, and how the home was hoping to develop over the next 12 months. Heathbrook House DS0000070913.V361618.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 X 4 Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 Heathbrook House DS0000070913.V361618.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Heathbrook House DS0000070913.V361618.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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