Inspection on 31/10/06 for Brocklehurst Nursing Home

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

Other inspections for this house

Brocklehurst Nursing Home 15/04/08

Brocklehurst Nursing Home 17/04/07

Brocklehurst Nursing Home 11/02/06

Brocklehurst Nursing Home 04/08/05

Brocklehurst Nursing Home 09/01/05

Brocklehurst Nursing Home 15/07/04

Brocklehurst Nursing Home 05/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brocklehurst Nursing Home 65 Cavendish Road Withington Manchester M20 1JG Lead Inspector Geraldine Blow Unannounced Inspection 31st October 2006 09:00 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 Brocklehurst Nursing Home DS0000021635.V317752.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. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brocklehurst Nursing Home Address 65 Cavendish Road Withington Manchester M20 1JG 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) 0161 448 1776 0161 434 3795 sharon.blackwell@anchor.org Anchor Trust Ms Cathryn Todd Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of patients for whom accommodation is provided at any one time shall not exceed 40 patients of either sex over pensionable age 11th February 2006 Date of last inspection Brief Description of the Service: Brocklehurst is a purpose built care home of 40 beds providing care with nursing for people over the age of 60 years. The home is on two floors with a passenger lift between the two floors. Accommodation is provided in 31 single and 5 double en-suite rooms with a variety of communal space for residents to use. The home is situated in West Didsbury on the site of the old Withington Hospital. The home is situated on a reasonably busy road used by local traffic. The centre of West Didsbury is about a quarter of a mile away. Main roads giving ready access to Manchester and the motorway network are close by. The charges for fees range from £491.60 to £610 per week. There are additional charges for magazines, papers hairdressing and holidays. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 11 February 2006 and some supporting information received in the pre-inspection questionnaire submitted by the home prior to this visit as well as 7 returned residents comment cards. This visit was an unannounced site visit, which forms part of the overall inspection process, and took place on Tuesday 31 October 2006. The opportunity was taken to look at all the key standards of the National Minimum Standards (NMS) and the requirement made at the inspection in February 2006. This inspection was also used to decide how often the home is to be visited and to make sure that it meets the required standards. As part of the visit, time was spent talking with the manager, the acting manager several members of staff, assessing relevant documents and files and a tour of the premises was undertaken. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people who have been appointed by Help the Aged, under the direction of the Commission for Social care inspection, to take part in the inspection of services for older people. Mr Tommy Walsh an Expert by Experience joined the inspector on this site visit. Mr Walsh spoke to residents and observed resident and staff interactions his comments and observations are included in this report. The requirement from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 6 What the service does well: As found at the last inspection the home provides a clean, safe caring environment for the residents who live there. The home carries out a pre admission assessment before a resident is admitted to the home to make sure that the home can meet the person’s needs. The home has an open visiting policy and staff spoken to confirmed this. From observations made and from talking to staff it appeared that the privacy and dignity of residents was protected and that residents were able to have choice with regard to their every day life. One comment received from the returned residents comment cards said “I feel this is the best place for me, standards are very high, I am happy here”. A choice of meals was available at each mealtime and the head chef and staff spoken to confirmed that residents can have any reasonable alternative to the meals on the menu and drinks and snacks are available on request. On the day of this visit the Expert by Experience joined the residents for lunch and the Expert commented that the meal was “quite nice and well cooked. The dining room was quite large and very airy also I found that in one of the lounges there was fresh fruit available”. The home had a good programme of activities available, which included arts and crafts, an exercise afternoon, hand massage, reminiscence/general discussion groups and a concert afternoon. The home recently had a trip to Blackpool to see the lights and photos were on display of a weekend break to Wales this summer. The home offers training for staff to ensure that they have the necessary skills to meet the needs of the residents’ accommodated. The home has a robust recruitment procedure to ensure that staff employed are safe to work with residents. The home had a complaint procedure, which every resident had a copy of and the manager was pro active in dealing with residents and relative/concerns. Comments received from the resident comment cards inclided “I feel I can approach staff and they will listen to what I have to say” and “I have never had to make a complaint in the 4 years I have been at the home”. It was encouraging that after spending the morning with the residents and observing staff interaction the Expert by Experience felt that this “was a friendly home and well run and that the staff was very caring”. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 7 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. Brocklehurst Nursing Home DS0000021635.V317752.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 Brocklehurst Nursing Home DS0000021635.V317752.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of prospective residents’ care needs prior to their admission. EVIDENCE: The home has a documented pre admission assessment form that is used to ensure that prospective residents are only admitted on the basis of a full assessment and evidence was seen that for residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment. It is recommended that following the pre admission assessment of a prospective resident the home confirms in writing to the resident that the home is able/not able to meet their assessed needs. The home does not provide an intermediate care service Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some areas of the care planning process required improvements to ensure residents’ health and personal care needs are fully met. The systems and procedures for dealing with medicines needs to be improved in order to protect residents. EVIDENCE: Residents were registered with the local GP practice and evidence was seen that other health care professionals i.e. Speech and Language Therapists were accessed according to residents’ needs. A random selection of care plans were examined. The residents’ care file containing general admission information and assessments were kept in their own room and the plans of care were kept in a communal file for easier staff access. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 11 It was noted that although a general assessment or “pen sketch” was completed on admission for each resident a plan of care was not written and implemented until the 6 week review. In addition, it was noted in other files containing a care plan, that some identified care needs had not been included in the care plan. For example, in the files examined the residents required differing levels of assistance with hygiene needs but no care plan had been written to address these need. Also some of the plans of care were found to be vague and did not give sufficient and accurate detail to provide clear guidance to staff of the actions to be taken to meet the resident’s individual needs. For example, they contained comments such as “monitor as often as possible” and “needs appropriate footwear”. Evidence was seen of appropriate assessments. For example, falls risk assessments, waterlow assessments and manual handling assessments. However the manager confirmed that a continence assessment was not completed. The manager said that the home was working with the Continence Advisor and the home had a continence link nurse and she would discuss the issue with them both. Not all of the documentation in the residents’ care file had been signed and dated by the person completing it. A recommendation has been made to address this. The care planning process and the subsequent documentation was discussed as length with the manager, the deputy manager and an RGN. The manager said that it was her intention to completely review the process and implement a plan of care on admission that would be reviewed an updated at the 6 week review. All medication received into the home and returned medication had been appropriately signed for and there was a sample list of staff signatures. On examination of the Medicine Administration Record (MAR) sheets, it was noted that there were several gaps in the recording of medication. In order to provide an accurate audit trail all prescribed medication must be signed for by the person administering them. Medication with a limited life, for example, eye drops, once opened did not have a recorded opening date and therefore an expiry date could not be determined. On examining the Controlled Drugs cupboard it was noted that a bottle of Temazepam liquid, dated 7/4/06, that was no longer in use continued to be stored in the cupboard along with the bottle currently being used. Excess drugs no longer being used should not be stored in the home. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 12 It was noted that a prescribed thickener, which is used to thicken drinks and soups for residents with swallowing impairment had only been signed for once a day on the MAR sheet. In order to ensure that residents care needs are being met it is vital that a record is maintained of each drink / soup etc that has been thickened and any other liquid the residents have had to drink. It is essential that the person making the drink signs a sheet, this does not have to be the nurse and it does not have to be signed on the MAR sheet, a separate drinks sheet may be constructed for each resident. In addition, it is essential that the information for thickening must be accurate. The dietician will give detailed advice and this must be readily available to all staff involved in the preparation of drinks / food for a resident. A record was seen that the temperature of the drug fridge was in the “safe zone”. The acting deputy manager said that this should be recorded on a daily basis, but on examination it had not been completed daily. To ensure that medication is being stored at the correct temperature it is recommended that the actual temperature is recorded on a daily basis. The home had 4 drug trolleys in use and each trolley was found to be stored, secured to the wall, in residents’ bathrooms. Some medicines need to be stored in such a way that the products themselves are not damaged by, for example heat or dampness. Therefore medicines must not be stored in damp or steamy places such as bathrooms. From observations made during the visit and discussions with members of staff it appeared that the nurses and care staff treated the residents with respect and dignity. In addition it was noted that residents preferred term of address was documented in their care file. Brocklehurst Nursing Home DS0000021635.V317752.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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were able to maintain contact with family and friends. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: Residents are consulted about their social interests and personal preferences by the completion of a social history and a social care plan questionnaire on admission. A ‘recreation team’ from Withington Hospital go into the home daily, Monday to Friday, to provide a variety of activities, which have already been reference in this report. On the day of this visit there was a concert in the main lounge, which the residents appeared to enjoy. It is recommended that the home keep a record of what activity each resident takes part in. It was encouraging to note that photos were on display of residents enjoying various activities and photos of a recent holiday in Wales. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 14 All staff and residents said that the home facilitated open visiting and visitors could be received in the residents’ own room or any of the communal areas of the home. Details regarding Advocacy services were on display in the home and the manager said that Age Concern acted as advocates for 2 of the residents accommodated. From speaking to staff it appeared that residents were able to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home. The menu examined demonstrated that the home provided a varied diet, which was nutritionally balanced and included adequate supplies of fresh fruit and vegetables. The head chef and staff spoken to confirmed that an alternative to the main meal was available at each mealtime or any reasonable alternative was available to residents. A tour of the kitchen was made. The kitchen was found to be clean and well organised. Adequate supplies of food were seen which included fresh fruit and vegetables. All food was seen to be stored appropriately. The Expert by Experience ha the opportunity to with 6 of the residents in the lounge area who were being encouraged by a member of the local NHS to discuss music and poetry. It gave the Epxert the chance to speak to the residents and commented that “they all seemed very pleased with conditions at the home. They appeared well groomed and happy. They said that the food was good and that they had live entertainment each Tuesday afternoon and that on Wednesday afternoon they were involved with physical exercising. Each week they had a manicurist attend to them at no cost and that hairdressing was available but there was a charge for that. Gents had haircut for £3.50 for example and perms etc., for the Ladies were very reasonable”. The residents also told the expert that they had recently had a trip to Blackpool lights and those who were able to go had trips out to local restaurants on a regular basis. Plans were in hand for Christmas celebrations. The Expert asked the manager if any celebrations were planned for Halloween but the manager confirmed that nothing had been planned. However there was evidence that the head chef had made pumpkin soup and pumpkin pie to accompany the evening meal and pumpkin lanterns had been made and were going to be put in the dining room during the evening. The Expert reported that he was told that at one time the home had a committee formed from the friends and relatives of the residents but the manager said that it no longer functioned as the turn over in residents was a regular occurrence and the committee consequently changed and at the moment there was no real demand for a committee. The Expert felt this was a pity as this would be a good source of feedback for the Management. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 15 The Expert also noticed that staff did not wear uniforms, other than kitchen staff, which was felt to be positive as it made it more home-like rather than institutional. A couple of staff spoken to by the Expert had worked at the home for a good number of years and he felt comforted by this. It was also noted that one of the helpers who led activities, had a dog, which the residents seemed to fuss. The expert asked whether residents were also allowed to have pets and the manager said that the rules of the home allowed pets but none of the residents had one. The Expert had a meal whilst he was at the home and he said it was “quite nice and well cooked”. He said the dining room was quite large and very airy also he found that in one of the lounges there was fresh fruit available. The Expert saw the week’s menu on display and said it was quite varied. The residents told the Expert that prior to retiring to bed they were given a milky drink if they wanted one or tea or coffee. One particular resident spoken to by the Expert seemed unhappy with the home for a number of reasons. The Expert felt that he wanted to speak to the manager about this. The manager assured the Expert this was not the case and that some of the comments made by this resident was as a consequence of their ill health and the Expert felt reassured by the manager. The issues were also discussed at length with the inspector who was also satisfied with the explanation given by the manager. Brocklehurst Nursing Home DS0000021635.V317752.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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home encourages and supports people to raise their concerns and complaints. However, residents were not fully protected from abuse, as not all staff had received the appropriate training. EVIDENCE: The home had a complaints procedure and the manager said that all residents had been given a copy. All complaints were logged and investigated. The manager said there had not been any complaints since the last inspection visit in February 2006. There had been no complaints direct to CSCI. The manager said that she encouraged resident/relatives to bring any concerns to her so that they can be addressed as a priority. The home had an Adult Abuse policy, however this should be reviewed and amended, as it does not accurately reflect the Adult Protection Procedures, ‘No Secrets Guidance’. The policy was dated May 2002 and stated that the homes manager would “carry out an immediate investigation”. In order to protect the residents living at the home this should be done as a matter of some urgency. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 17 The staff spoken to said that they had received training in the Protection of Vulnerable Adults (POVA). However, from discussions with the manager and reviewing the training records not all staff had received the training. In order to protect the residents living at the home all staff must receive POVA training, which includes the actions to be taken in the event of an allegation of abuse. Brocklehurst Nursing Home DS0000021635.V317752.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home were clean, comfortable, well maintained and equipped to meet the needs of the residents. EVIDENCE: The home has its own handyman who maintained the building appropriately and dealt with minor matters when they were raised with him by staff or residents. The accommodation is well furnished and is suitable for the residents living there. On the day of this visit the home was odour free and was found to be clean and tidy. The home offered a variety of communal areas, which included a number of lounges on both floors of the home, a dining room and a hairdresser’s room. The garden area was well maintained and accessible to Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 19 residents. homes. Bedrooms were personalised with items brought in from resident’s The home is naturally well ventilated. The baths were found to be delivering hot water at a safe temperature; the handyman checks this regularly. Brocklehurst Nursing Home DS0000021635.V317752.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared sufficient to meet the residents’ assessed needs. The procedures for recruiting staff were robust and appeared to provided adequate safeguards to protect residents. EVIDENCE: At the time of this visit the home accommodated 40 residents. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. The home employed 26 care staff, 9 of which had achieved NVQ level 2 and a further 4 members of care staff were currently undertaking the training. It was encouraging that the acting deputy manager was undertaking the NVQ Internal Verifiers course. The staff files examined contained the appropriate documentation as required by Schedule 2 of The Care Homes Regulations 2001, with the exception of one file that did not contain a photograph. A recommendation has been made. The manager said a set interview format is used and notes are taken, however Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 21 the notes are not kept following the interview. It is recommended that the notes taken during interview be kept for reference if needed. Staff spoken to said that they were happy with the level of training received and evidence was seen that regular training was provided that included Manual Handling, Health and Safety and Medication Management. However, for a variety of reasons, described by the manager, some staff had not received Fire Safety training and as already referenced in this report POVA training. The manager said it was her intention to address the issue. The manager said that all newly recruited members of staff must complete the structured induction training which is a programme develop by Anchor. Brocklehurst Nursing Home DS0000021635.V317752.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates in the best interests of the residents. EVIDENCE: As referenced in the last report the manager has worked at the home for over 15 years and is a registered nurse. She had the Registered Managers Award and also a Masters Degree in gerontology. She demonstrated a clear view of the need to continually develop care services in the best interests of the residents. Evidence was provided that the home had appropriate service contracts in place for equipment and installations used in the home and that servicing is undertaken at the required intervals to ensure the safely of residents. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 23 Evidence was seen that the systems in place did safe guard residents’ financial interests and secure facilities were provided for money and valuables held on behalf of residents. The home undertakes an annual self-assessment audit, using a corporate Anchor Homes tool. As part of this audit questionnaires are sent to residents, relatives and staff to obtain their views of the home. It is recommended that a questionnaire is also sent to visiting professionals in order to obtain their views of how they felt the home is achieving goals for residents. It is also recommended that the manager produce an annual development plan based on the results of the quality assurance questionnaires. Brocklehurst Nursing Home DS0000021635.V317752.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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Brocklehurst Nursing Home DS0000021635.V317752.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 OP7 Regulation 15 (1) Requirement Each resident must have a written plan of care setting out individual resident’s needs in respect of their health and welfare are to be met. This must be undertaken in consultation with the resident or their representative. 1. The registered provider must make arrangements for the accurate recording of medication. Timescale for action 01/12/06 2. OP9 13 (2) 01/12/06 3. OP18 13 (6) 4. OP30 23 (4) (d) 2. The registered provide must provide appropriate storage of medication. The registered provider must 01/12/06 make suitable arrangements to ensure that staff receive training on how to protect and keep residents’ safe from harm and abuse or being placed at risk of harm or abuse. The registered provider must 31/12/06 make arrangements for persons working in the home to receive suitable training in fire prevention. Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 26 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 OP3 Good Practice Recommendations It is recommended that following the pre admission assessment the home confirm in writing, to the prospective resident, that the home is able/not able to meet their assessed needs. 1.It is recommended that all parts of the individual plans of care are singed and dated by the person completing them. 2. It is recommended that an assessment of continence needs is completed on admission. 1. It is recommended that the actual temperature of the drug fridge is recorded on a daily basis. 2. Controlled Drugs that are no longer required by a resident should not be stored in the home. It is recommended that the home introduce the use of an individual activity record. It is recommended that the registered provider review and amend the Protection of Vulnerable Adults policy to ensure that it accurately reflects the Adult Protection Procedures ‘No Secret Guidance’. 1. It is recommended that all staff files contain a recent photograph. 2. It is recommended that the notes taken during interview be kept on the staff file for reference if required. 1. It is recommended that the quality assurance questionnaire is sent to visiting professionals in order to obtain their views of how the home is achieving goals for residents 2. It is recommended that the manager produce an annual development plan based on the results of the quality assurance questionnaire. 2. OP7 3. OP9 4. 5. OP12 OP18 6. OP29 7. OP33 Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Brocklehurst Nursing Home DS0000021635.V317752.R01.S.doc Version 5.2 Page 28 - 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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