Inspection on 15/07/08 for Brook House

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate 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.

Other inspections for this house

Brook House 06/05/08

Brook House 18/12/07

Brook House 18/09/07

Brook House 07/11/06

Brook House 21/10/05

Brook House 05/05/05

Brook House 07/12/04

Brook House 11/05/04

Brook House 02/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Brook House 72 High Street Riseley Bedfordshire MK44 1DT Lead Inspector Mrs Louise Trainor Unannounced Inspection 15th July 2008 10:00 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 Brook House DS0000014887.V368189.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. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook House Address 72 High Street Riseley Bedfordshire MK44 1DT 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) 01234 708077 01234 709712 lesleyh@gotadsl.co.uk Riseley Beds Limited Mrs Lesley Atkinson Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Physical disability over 65 years of age (20) Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is permitted to accommodate one named service user (Variation V26762) in the category of DE from 01 December 2005 up to their discharge from the home. 6th May 2008 Date of last inspection Brief Description of the Service: Brook House is a listed building located in the village of Riseley in North Bedfordshire. The building was extended during 1995 and now provides accommodation for up to 20 older people. The ground floor is split level the lower part housing two communal areas and the higher level some bedrooms a dining room, kitchen, laundry, bathing and toilet facilities. Access to the top floor of the home is via a staircase fitted with a stair-lift, the remaining bedrooms, bathrooms and toilets are located on this floor. A day care facility for the use of residents and people in the surrounding area is available in an adjacent building. Car parking spaces for several vehicles is available to the front and side of the home. To the rear of the building is a raised garden that is accessed via a slope. The statement of purpose for the home identifies that the home is unable to accommodate residents who are unable to manage the stairs, which connect the split-level lower floors. The fees for this home have recently been reviewed and are now ranging from £420.00 to 480.00 per week. Brook House DS0000014887.V368189.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was a Key Inspection, and it was carried out on the 15th of July 2008 by Regulatory Inspectors Mrs Louise Trainor and Mrs Sally Snelson, between the hours of 10:00 and 13:45 hours. The home Manager was present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care of two people were case tracked. This included the most recent admission to the home, and someone who had recently passed away. This involved reading their records and comparing what was documented to the care that was, or had been provided. Documentation relating to: staff recruitment, training and supervision and medication administration were also examined. One of the inspectors spent the majority of the visit in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this three and three quarter hour inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Admissions are not made until a full assessment of needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. The home attempts to provide a service that is as individual as possible, and generally residents are consulted on choices. Some residents are consulted and encouraged to participate in activities, however this process could be improved. Since the last inspection, evidence indicated that the manager is now taking more control and responsibility for areas that we previously felt she was rather detached from. Supervision has now been reviewed in the home, and the manager and her deputy are addressing all supervision between them. The records that we looked at indicated that appropriate issues are being discussed and recorded appropriately. At the last inspection in May 2008, immediate requirements were left relating to medication storage and records. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 7 During this inspection we checked the Medication Administration Record (MAR) sheets and the blister packs. These all corresponded correctly. At the previous inspection we were concerned that the home was being used as a delivery and pick up point for prescriptions for local villagers that were unable to get to the surgery, and there were no records being kept to identify when these were collected, or who collected them. The home has now introduced a record book which individuals sign when they collect their medication from the home. Since our last visit, the manager has started to address quality assurance. In June questionnaires were issued to visitors and relatives. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures in the home. More work is needed in this area. Health needs are monitored and appropriate action and interventions taken. People using this service are happy with they way most staff deliver their care and respect their dignity. What they could do better: We observed the activities taking place during the morning. In one lounge three gentlemen were enjoying a game of dominoes. Unfortunately this room doubled up as an area for staff to take their breaks. It would have been more appropriate for staff to take their breaks in ‘a non resident’ area. There were improvements noted in the outcome area relating to activities, however it is still evident that more work is needed to ensure that all residents’ needs are being met, and their choices addressed. The service recognises the importance of training and tries to deliver a programme that meets the requirements of the home. However there are presently some shortfalls and gaps in the training records that are being addressed. Since our last visit, the manager has started to address quality assurance. In June questionnaires were issued to visitors and relatives. The report identifies that 33 of responses felt that the home could be improved, and 67 did not comment. We expect to see further investigation of how the home can make these improvements, and an action plan to demonstrate what actions have been put in place to achieve these improvements. Medication records are generally up to date, however present confusion over omission codes prevents accurate reconciliation. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 8 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. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 9 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 Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3, 6 People who use this service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Admissions are not made until a full assessment of needs has been carried out, so that prospective residents and their representatives can be sure their needs will be met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: There is a Service User Guide and a Statement of Purpose in place for this home and both documents had been reviewed within the last year. Although there is no evidence of the range of fees charged for living in this home in either document, the details of fees are issued on a separate sheet, which is Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 11 updated regularly and enclosed with all documents sent to prospective service users with their contracts. We viewed the file of the only new resident since our last inspection in May 2008. The pre admission assessment had been carried out well in advance of the admission. It contained sufficient detail to ensure that staff would be able to meet his needs. This was an issue that had generated requirements at the last inspection, and has now been addressed. The latest admission to the home also had a contract that had been clearly signed and dated by the appropriate parties. This home does not provide an Intermediate Care Service. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 12 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, 11 People who use this service experience adequate quality outcomes in this area. Health needs are monitored and appropriate action and interventions taken. People using this service are happy with they way most staff deliver their care and respect their dignity. Medication records are generally up to date, however present confusion over omission codes means that reconciliation is not always accurate. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The files of two residents were examined during this inspection. One of these residents had been the only admission since the previous inspection in May 2008, and the other was the file of a resident that had recently passed away. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 13 The new admission had a detail pre admission assessment in place that had been clearly dated and signed. It gave information relating to the level of assistance this individual required and gave examples of when and why this person may become anxious or agitated. The care plans were specific in detail and included information such as. “Can wash and dress with supervision, carers need to do buttons and zips and put on footwear. Becomes anxious in unfamiliar surroundings, sleeps well but can become aggressive if disturbed, walks independently without any aids, wears a small pad as sometimes finds it hard to get to the toilet, weak on right side and has difficulty using right arm and hand”. It also included some information relating to this persons preferences, such as likes to watch sports on television. Generally this individual’s notes were well detailed and had been reviewed to reflect changes. On admission there was no history of falls recorded, however as this person had had six falls in June, the care plan had been altered and safety measure put in place. This persons next of kin had signed these care plans. Risk assessments relating to dependency and nutrition were appropriately completed. The second file we looked at clearly recorded this person’s deterioration and how it was managed. It indicated that this person’s end of life was managed in a dignified and sensitive way, and the need for pressure relieving equipment had been identified, and acted upon. We spoke with a visiting district nurse during our visit. She told us that she attends the home most weeks. She confirmed that staff in this home are very good at reporting any changes in resident’s conditions, and said that residents are always ready when she visits to do individual’s dressings. She informed us that she had been involved with the management of a resident that recently passed away, and confirmed that the staff had been proactive in ensuring appropriate pain relief would be available if it was required during ‘out of surgery’ hours. At the last inspection in May 2008, immediate requirements were left relating to medication storage and records. During this inspection we checked the Medication Administration Record (MAR) sheets and the blister packs. These all corresponded correctly. We picked five resident’s ‘as required’ medication at random to reconcile. All reconciled correctly with the exception of one, which was confusing, as the wrong code had been applied to an omission. The home has recently changed their pharmacy supplier, which has involved a new MAR sheet, however staff are still using the old omission codes from the previous supplier. The manager assured us she would address this immediately to avoid any further confusion. The next month’s medication supplies had been delivered three days previously and were still waiting to be signed in, however the previous months charts did indicate that this is now being done accurately so that stocks and returns can be reconciled correctly. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 14 At the time of this inspection there were no residents on controlled drugs. The cupboard was checked and was empty, and the register recorded all returns correctly. At the previous inspection we were concerned that the home was being used as a delivery and pick up point for prescriptions for local villagers that were unable to get to the surgery, and there were no records being kept to identify when these were collected, or who collected them. The home has now introduced a record book which individuals sign when they collect their medication from the home. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 15 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 adequate quality outcomes in this area. The home attempts to provide a service that is as individual as possible, and generally residents are consulted on choices. Some residents are consulted and encouraged to participate in activities, however this process could be improved. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: As at the previous inspection, the sun was shining and laundry was hanging out to dry in the courtyard, and it was heart warming to see one or two of the residents checking to see if the laundry was dry, as this is a daily activity that many of the ladies who live in this home may remember as part of their daily routines We observed the activities taking place during the morning. In one lounge three gentlemen were enjoying a game of dominoes. Unfortunately this room Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 16 doubled up as an area for staff to take their breaks. It would have been more appropriate for staff to take their breaks in ‘a non resident’ area. In the other lounge the ‘activities carer’ was attempting to do a quiz with eight residents. Two of these residents were really interested and engaging well, one person who had problems with communication, was using charts to assist her interactions, this was very positive. However it may have been even more effective if the television in this lounge had been switched off during this activity. Four of the residents in this group were sleeping, and one was wandering around the room. Another resident walked into the lounge and cried. “I can’t go on like this” and walked out again. No one was seen to reassure her. Another resident had a visitor that had come to take her out. There were no staff around and the resident seemed anxious that her visitor was going to help her get ready. During this period of observations, a member of staff came in and gave everyone drink. There was no choice offered, each person was just given a mug of drink, and although staff were aware of personal preferences, this was a lost opportunity to interact and give residents the chance to change their minds, and have something different from the expected norm. So although there were improvements noted in this outcome area relating to activities it is still evident that more work is needed to ensure that all residents’ needs are being met, and their choices addressed. The fridge and freezers in this home were well stocked with both fresh and frozen produce. A large gammon joint was defrosting in preparation for tomorrow’s meal. The menus in the home have been reviewed, and the choice of midday meal on the day of the inspection was Derbyshire Hotpot or Cheese pasties, both served with potatoes and fresh seasonal vegetables. The food looked, smelt and tasted very appetising. Dessert was ice cream sundaes or fruit, and the cook was baking ginger cakes for tea. The supper menu consists of lighter choices such as soup, pizzas, burgers and sandwiches. Residents confirm that this is quite sufficient. The cook told us that each resident is verbally given a choice of their meals every morning. We discussed using photographs to offer choices to those with more severe cognitive impairment, and although there are presently very few residents in this home that fall into that category, the cook was quite enthusiastic about this. We look forward to seeing how this progresses in the future. We had the opportunity to speak with one visitor, she was very satisfied with the care her loved one received. She said. “---- is in her fifth year here, we’re very happy, I am very satisfied, she is well looked after and kindly so.” Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 17 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 quality outcomes in this area. This home keeps a full record of all complaints, and this includes details of any investigation and actions taken. Safeguarding training for staff id regularly arranged by the home. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints procedure that is clear and easily accessible. During this inspection we examined the complaints file. There had been no written complaints received since the last inspection in May 2008. The home do however complete a complaints log for any issue of concern raised by staff, residents or their relatives. We looked at several of these and all had detail of how the concern was managed and what actions were taken to resolve it. The issues that we looked at had also been recorded in individual’s care notes where appropriate. Previously we had concerns that there was limited understanding about safeguarding reporting in this home and we felt that there was an “it couldn’t happen here” mentality amongst staff. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 18 Since January 2008 the majority of staff have attended safeguarding training and the manager and her deputy have attended a seminar, which included lectures on Safeguarding, the Mental Capacity Act and Advocacy issues. The manager was very positive about this seminar and is planning to cascade this information to her staff at the next staff meeting on the 31/07/08. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 19 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, 25, 26 People who use this service experience good quality outcomes in this area. This home provides a clean, comfortable and homely environment for the people who live here. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home was clean and free from any offensive odours. There is an enclosed courtyard with garden furniture, giving the residents the freedom to wander safely, unaccompanied in the fresh air if they so wished. There is a large rear garden laid mainly to lawn with mature shrubs surrounding the perimeter. The manager has recently purchased half a dozen chickens, which are penned at the back of the garden. These are an interesting feature for some of the Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 20 residents who have always lived in a rural location, or have a farming background. The manager told us that four particular residents have shown interest in them already and she plans to take photographs of each chicken and invite all the residents to choose names for them. Toilet and bathing / shower facilities are sufficient in this home, and individual rooms are decorated and furnished to personal taste. Some rooms contained furniture that individuals had brought into the home with them, giving each one a feeling of individuality. Photographs and personal assets reflecting individuals’ life history also enhanced a homely atmosphere. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 21 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 adequate quality outcomes in this area. The service recognises the importance of training and tries to deliver a programme that meets the requirements of the home. However there are presently some shortfalls and gaps in the training records that are being addressed. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: On the day of this inspection there were three care staff, one carer solely for activities, two cleaners, one cook and the manager on duty. The manager explained that she is now putting one carer on duty each shift to cover activities. There are twenty-three care staff including the manager and her deputy on the rotas, and no one works in excess off forty five hours a week. We examined the personal files of three staff that had been appointed since our last inspection. All three had Criminal Record Bureau checks and POVA first checks in place. All had fully completed application forms that detailed employment history and personal qualifications. We did however have to Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 22 question why one of the applicants references were both from friends, when she had previously worked in a caring capacity. The explanation from the manager was that this person’s previous care role had been in a voluntary capacity, and the manager did not think this would be acceptable. We were also later informed that one of the ‘friends’ was a colleague from her previous job. This information should all be documented in the individual’s files. All three of the new staff are presently working through an induction programme, which involves the completion of a booklet over a given period of time. We were unable to view these booklets as they remain with the individual, not with the manager. These employees did not yet have signed contracts. We viewed training documentation. Mandatory training is provided on a rolling programme. For example infection control training was held on the 12/06/08, with a further session on the 24/07/08, moving and handling was held on the 20/06/08, with another session arranged for 24/07/08. The manager expects all staff will have attended by the end of this period. Records show that the majority of staff have undertaken safeguarding training since January 2008. We were a little concerned that two of the three new staff have not yet done this training, however rotas confirmed that they are working under supervision. Three staff in the home are presently being trained and assessed by the district nurse and the diabetic nurse, so that they will be competent in the administration of insulin. The home has booked an ‘Experiential Workshop’ for the 14/08/08. It is estimated that a dozen staff will attend, and the manager hopes that this will give staff some idea of what it is like to live with some of the disabilities experienced by their residents. This will hopefully help them appreciate more fully the way in which they deliver care. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 23 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, 36, 37, 38 People who use this service experience adequate quality outcomes in this area. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures in the home. More work is needed in this area. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection, evidence indicated that the manager is now taking more control and responsibility for areas that we previously felt she was rather detached from. She has taken responsibility for reviewing and re writing the Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 24 care plans, and ensuring that other staff are clear in their understanding of what is expected. We looked at some work that a key worker had done providing information for a care plan. This was very clear and specific in detail, and demonstrated a thorough understanding of what was required. We looked at records in general. These were much improved, dated and signed. We expect this to continue. One person told us. “There have been lots of changes, staff are looking at care plans and making suggestions for additions and changes. The manager is distancing herself from staff more, making things more professional, and although some staff have found this difficult, she has more respect now and they know she’s the manager”. Accidents and incidents are being appropriately reported to The Commission for Social Care Inspection (CSCI) and other agencies as required. The home manages ‘personal allowance money’ for all of the people who live there. At a previous inspection in December 2007, we were concerned to find a number of discrepancies in the records, however at a follow up compliance visit in January 2008, records were found to be correct. It was therefore very disappointing, when errors were again found during the inspection in May 2008. However during this inspection we closely checked all nineteen residents personal allowance records. All were found to be correct. The Responsible Individual and/or the Registered Manager are auditing these records monthly. We expect this level of auditing to continue, as improvements have been seen previously but not sustained. At the previous inspection we were concerned that supervision was not being appropriately managed in this home. The managers’ involvement was minimal and the supervisor’s role had been delegated to two senior carers, who had not undergone training to carry out this role. They were also supervising each other through issues, which should have been supervised by the manager. This has now been reviewed in the home, and the manager and her deputy are addressing all supervision between them. The records that we looked at indicated that appropriate issues are being discussed and recorded appropriately. Continued work is needed by the manager to bring this up to with minimum standards, however it was encouraging to see the progress to date. We were concerned that at this early stage of improvement the manager was already talking about delegating this role to a newly promoted senior carer. It is essential that the manager continues to demonstrate that she is in control of, and accountable for, all these core procedures to ensure sustainability of improvements. We inspected the water temperature check records, and those for the fridge, freezer and food probing temperatures. These were all being done as required. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 25 Since our last visit, the manager has started to address quality assurance. In June questionnaires were issued to visitors and relatives. The report identifies that 33 of responses felt that the home could be improved, and 67 did not comment. We expect to see further investigation of how the home can make these improvements, and an action plan to demonstrate what actions have been put in place to achieve these improvements. The manager is presently working on responses from a staff questionnaire, however this is in the early stages. The manager has not yet included other professional disciplines in her quality audit process. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 26 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 3 3 Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 27 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 OP14 Regulation 12 (2) Requirement People who use this service must be encouraged to make personal choices in a way that they understand. People who live in this home and their representatives must have access to a report detailing the quality review of the home. This report must also be submitted to CSCI within the given timescale. Staff must receive a minimum of six supervision sessions a year from an appropriate supervisor. Previous requirement 30/06/08 – partially met timescale extended. Timescale for action 30/09/08 2. OP33 24(2) 30/09/08 3. OP36 18(2) 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Brook House Refer to Good Practice Recommendations DS0000014887.V368189.R01.S.doc Version 5.2 Page 28 1. Standard OP15 The home should consider using picture menus to assist those residents with cognitive impairment in making choices. Brook House DS0000014887.V368189.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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