Inspection on 18/12/07 for Brook House

This inspection was carried out on 18th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brook House 15/07/08

Brook House 06/05/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brook House 72 High Street Riseley Bedfordshire MK44 1DT Lead Inspector Mrs Louise Trainor Key Unannounced Inspection 18th December 2007 16:00 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.V356853.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.V356853.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.V356853.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. 18th September 2007 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 460.00 per week. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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 the second Key Inspection for this service this year. It was carried out on the 18h of December 2007, by Regulatory Inspectors Mrs Louise Trainor and Mrs Sally Snelson, between the hours of 16:00 and 19:00 hours. The first inspection had only been carried out three months previously but the manager had made a request for this to be carried out before the 19th of December 2007. The home Manager was not on the premises when we arrived for the inspection, but was contacted by staff and returned immediately. She was then present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout and at the end of the visit. During the inspection the care of three people who use the service were case tracked. This involved reading their records and comparing what was documented to the care that was 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- hour inspection. What the service does well: There is a Service User Guide and a Statement of Purpose in place for this home and both documents had been reviewed in June 2007. We picked the contracts of five people who live in this home at random to check. These were all signed and dated appropriately. There are a wide variety of activities available in this home, and individual people who use this service are encouraged to pursue personal interests. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 6 Menus offered to the people who live in this home are varied so that personal choices maybe exercised. This home provides a clean, comfortable and homely environment for the people who live here. What has improved since the last inspection? What they could do better: Repeated non- compliance in key areas relating to recruitment, individual’s finances and medication, indicates that the manager lacks control of some of the main components involved in the running this home and the protection of the people who live there. There was limited documentary evidence to indicate that assessments are carried out on the people who live here prior to their admission, therefore their needs may not be clearly identified and fully met. Systems in place for the administration of medication remain insufficient to protect the people who live here. The majority of staff in this home have now completed training in safeguarding, and staff that were interviewed during this inspection were able to demonstrate their understanding of the processes involved. However we continue to have concerns that all incidents that fall into the category of safeguarding referrals, are not being reported as such. Systems for the recruitment of staff are insufficient to ensure that people who live in this home are protected. Staff are undergoing mandatory training in this home, however there was a distinct lack of enthusiasm from some staff that made it very clear that they have worked in the home for many years and have no wish to progress with any further training. The manager is now coordinating the supervision of the staff. She has delegated the senior staff to supervise a team of staff each. This process is only in the early stages and records for inspection were limited. The manager Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 7 also stated that she had not received any supervision herself since the previous inspection. The home manages ‘personal allowance money’ for many of the people who live there. The records for six individual’s accounts were inspected. Only one of the six accounts balanced with the funds remaining. 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.V356853.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 Brook House DS0000014887.V356853.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): 1, 2, 3, 4, 6, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was limited documentary evidence to indicate that assessments are carried out on the people who live here prior to their admission, therefore their needs may not be clearly identified and fully met. EVIDENCE: There is a Service User Guide and a Statement of Purpose in place for this home and both documents had been reviewed in June 2007. 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 updated regularly and enclosed with all documents sent to prospective service users and enclosed with their contracts. We picked the contracts of five people who live in this home at random to check. These were all signed and dated appropriately. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 10 There had been an issue raised at the previous inspection in September relating to pre admission assessments not being clearly dated. The manager informed us that there had only been one permanent admission to the home since the last inspection. Unfortunately she was unable to locate the pre admission assessment that she said had been carried out for this person. She said that she thought that the nurse who carried it out must have locked it away. None of the files that we inspected contained pre admission assessment, however on the day of the inspection someone had just been admitted for a two- week respite period. There was a pre admission assessment present for this individual that had been carried out the day before in hospital. This home does not provide an Intermediate Care Service. Brook House DS0000014887.V356853.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): 7, 8, 9, 10, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The individual care plans in this home were of a very high standard, however systems in place for the administration of medication remain insufficient to protect the people who live here. EVIDENCE: Since the last inspection the staff in this home have worked very hard to improve the standard of care plans. Individual’s needs and problems were now clearly identified and written in plain English so that everyone delivering their care could easily understand them. There was a clear list of instructions that identified how the care should be delivered, and this included details of personal preferences. The individual plans were being reviewed on a monthly basis to ensure that any changes in needs were being appropriately addressed. One person’s plan, that was inspected, clearly indicated that there had been deterioration in their condition. It identified changes in pain relief being addressed, a loss of weight, which was brought to the attention of everyone Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 12 involved in her care, including the cook, and changes in the regime applied in moving this individual as their level of mobility had declined significantly. Another person’s file clearly indicated that this person preferred the use of assistance with a stick to being hoisted. A falls risk assessment had been completed on the 29/11/07, and the care instructions included the need to keep the room free from excessive furniture. However we had some concerns that this individuals risk assessment score had increased from ‘8’ on the 18/11/07 to ‘17’ on the 18/12/07. This increase in score, that indicated a major increase in risk for this person, according to documentation was due to; the individual’s mental state, visual impairment and communication abilities, however when the inspector spoke with this individual, she responded appropriately and there was little evidence to indicate that she was confused or had problems communicating, although she was hard of hearing. The manager was unaware of, and unable to explain the score changes on this risk assessment or why it indicated such a dramatic deterioration. The Medication Administration Record (MAR) sheets were checked for all the people who live in this home. There was a sample staff signature sheet present for reference purposes. On eight of the MAR sheets, there were blank spaces on them where omission codes and signatures for administration should have been recorded. In some cases the tablets were still remaining in the blister packs, and in others they were missing. This indicated that medication was being given but was not always signed for. At the time of the inspection there was only one person prescribed a ‘Controlled Drug’, the storage of the controlled drugs was inappropriate and unsafe. A requirement had been left at the last inspection in September to rectify this matter. ‘Boots’ the pharmacy confirmed by telephone, during the inspection, that a new controlled drug cupboard was on order, but they could not specify a date of delivery. The home had had three months to rectify this matter and had failed to do so, therefore they remain non compliant to this requirement. The records for the controlled drug in stock had also been completed incorrectly and did not reconcile with the stocks remaining. When this matter was discussed with the manager she stated that she would address this issue with those responsible immediately. She did not appear to recognise that she was ultimately responsible and accountable for these errors. A visit from the Commission for Social Care Inspection’s (CSCI’s) Specialist Pharmacy Inspector has been requested, and an Immediate Requirement was issued regarding the medication systems. Brook House DS0000014887.V356853.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 adequate. This judgement has been made using available evidence including a visit to this service. There are a wide variety of activities available in this home, and individual people who use this service are encouraged to pursue personal interests. Menus offered to the people who live in this home are varied so that personal choices maybe exercised. EVIDENCE: This home has an annex which has been purpose built as a day centre. It has twelve places and offers activities for both ‘outsiders’ and residents from the home. The care staff from Brook House also staffs this unit. As this inspection was carried out during the late afternoon and early evening, there were no organised activities to observe, however everyone in the home appeared relaxed and comfortable. Some were enjoying a ‘Midsummer Murders’ programme on the television, and others were wandering around different areas of the home busying themselves. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 14 We observed the serving of the evening meal in the home. Some of the residents were served in the dining room and others preferred their meals to be served in their bedrooms. There was however quite a time lapse between courses due to insufficient staff being present at this time of day. This resulted in some people, who were rather confused, wandering away from the tables, consequently causing considerable disruption, when mealtimes should be a relaxing and social experience. The evening meal consisted of a choice of tinned baked beans with sausages, bubble and squeak and/or bread and butter, or jam sandwiches, followed by a choice of cakes and chocolate biscuits. Although this was not a particularly nutritious meal, two of the people interviewed, indicated that this was quite sufficient as they had had a choice of chicken or lasagne at lunch time which had been very filling and so they only wanted something very light in the evening. Visitors are welcomed into this home at any time. One visitor told us. “This home is wonderful, they have looked after dad really well”. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Generally the staff in this home are trained and able to demonstrate their understanding of safeguarding procedures. However evidence throughout this report indicates that insufficient systems are in place to protect the people who live here. EVIDENCE: The complaints file was not examined during this inspection. The majority of staff in this home has now completed training in safeguarding, and the staff that were interviewed during this inspection were able to demonstrate their understanding of the processes involved. However we continue to have concerns that all incidents that fall into the category of ‘safeguarding referrals’, are not being reported as such. We saw three accident forms relating to incidents that had occurred in the week prior to the inspection. Two of these were unwitnessed falls, but to date, The Commission for Social Care Inspection (CSCI) has not received notification of these incidents. It has also been noted by the CSCI that on the 12/12/07, the manager and Responsible Individual for this home attended a safeguarding meeting armed with a letter, which could only be described as a statement of events from the alleged perpetrator. Although we appreciate that it maybe very difficult in Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 16 some circumstances to suspend staff, and refrain from asking questions about the alleged incident, the management of this home must understand that the decision of actions to be taken in these situations is that of the safeguarding panel and not themselves, and these processes must be adhered to at all times. During this inspection, we found evidence indicative of poor record keeping particularly in relation to ‘personal financial accounts’ and the recruitment of staff. This indicates that the systems that are in place to protect the people who live in this home are insufficient. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a clean, comfortable and homely environment for the people who live here. EVIDENCE: The home was clean and free from any offensive odours. It was tastefully decorated in preparation for Christmas and some residents had their personal Christmas cards displayed in the communal areas of the home. The lounges and dining areas were spacious and provided ample room for the people who live there to relax. 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 also a large garden at the rear of the property, however due to the layout and landscape this is only accessible under supervision. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 18 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. During this inspection we became aware that the doorbell at the front of the building could not be heard either in the kitchen or the office. Therefore when a visitor arrived at the home, it took a considerable time before they could gain access. The people living in the home are not able to open the front door and staff, who were all in the kitchen at the time had not heard it ring. We advised the manager that a doorbell extension might be an appropriate course of action, to avoid leaving visitors standing out in the cold for inexcusably long periods of time. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems for the recruitment of staff are insufficient to ensure that people who live in this home are protected. EVIDENCE: There had only been one new member of staff recruited since the previous inspection in September 2007. This member of staff was what the manager referred to as a ‘junior’ and was the relative of an existing member of staff. We checked the recruitment documentation for this person. The Criminal Record Bureau (CRB) check had not yet been obtained, and there was only one reference present. The application form had the date of birth completed as ‘3/11/99’, which was obviously wrong, and there were no interview notes present. When asked about these matters, the manager was unaware of these details and stated that the deputy manager was responsible for recruitment. As with the medication errors, we reminded the manager that she was ultimately accountable and responsible for all of these issues. An Immediate Requirement was left relating to this matter. During this visit to the home we spoke with all the staff on duty. Many of the staff work split shifts in the home, and some have full time jobs elsewhere. One member of staff was overheard saying. “I worked all night, I need to look at the off duty”. This indicated that some staff are working a combination of Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 20 both night and day shifts in one week. This is quite acceptable providing rest periods are appropriate, however we could not confirm this, as when we asked to view the present duty rosters for the home, the manager was unable to locate them. She has also failed to submit them to CSCI as had been requested at the inspection. There were three care staff on duty during the afternoon, however at 16:00 hours one of the carers took on the role of the cook until 18:00 hours, leaving just two to serve and assist with feeding of all the residents. This was insufficient staffing, and the staff looked harassed and tired, and they became noticeably upset when the manager asked for someone to assist a resident in their bedroom. Staff said. “How do we feed five people and care for the rest”? The mealtime observed could only be described as chaotic, with people getting up and wandering away from the table throughout the meal. The staffing levels on duty were insufficient for the number of people living in this home and the care and assistance they required. At 18:00 hours, two of the care staff went off duty and two more come on duty until 22:00 hours. One member of the staff coming on duty, asked a few questions and indicated she had already received some information from a relative that had been working in the home earlier that day, but there was very limited handover between these two shifts. One member of staff also said “often lately only two staff are on duty between the hours of 18:00 hours and 22:00 hours and it can become very hectic”. Staff are attending mandatory training sessions in this home, however there was a distinct lack of enthusiasm from some staff, who made it very clear that they have worked in the home for many years and have no wish to progress or attend any further training. This home is presently registered to accommodate twenty people within the categories: Physical Disability (PD), Mental Disorder (MD) and Dementia over 65 years. It is unlikely that with the present staffing levels and training programme, the home could appropriately care for this high level of mixed speciality care. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Repeated non- compliance in key areas relating to recruitment, individual’s finances and medication, indicates that the manager lacks control of some of the main components involved in the running this home and the protection of the people who live there. EVIDENCE: The manager has worked in this home for about twenty years. We were however rather concerned that despite the fact that she had requested this inspection, she was unprepared, some of the requirements from the previous inspection remained unmet, and new requirements were generated due to Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 22 major shortfalls in meeting some of the key standards. This included three immediate requirements. The relevant CSCI certificates were displayed in the entrance hall of this home, however there were out of date certificates with incorrect information on them also displayed. These should have been removed and returned to CSCI on receipt of the new ones. Similarly an old out of date insurance certificate also remained on display. The home manages ‘personal allowance money’ for many of the people who live there. The records for six individual’s accounts were inspected. Only one of the six accounts balanced with the funds remaining. The others all identified discrepancies ranging from 10p to £17.00. One account balance was £76.65, but there was only £76.15 funds remaining, another balance recorded £89.65, but there was £90.75 remaining in her account, and a third account records identified a balance of £17.58, however there was only 58 pence remaining in her account. Although most of the discrepancies were in the favour of the residents, this indicated that insufficient care is taken to maintain these records accurately. The manager is now coordinating the supervision of the staff. She has delegated the senior staff to supervise a team of staff each, and has carried out annual appraisals on most of the staff. However the supervision process is only in the early stages and records for inspection were limited. The manager also stated that she had not received any supervision herself since the previous inspection. The CSCI are receiving some regulation 37 notifications from this home which is an improvement since the previous inspection, however three accidents that had been recorded in the accident book up to four days prior to this inspection had not been received by CSCI at the time of the inspection. Two of these incidents were unwitnessed and involved individuals’ being found on the floor. These had not been reported through the safeguarding procedure. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 2 2 1 Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) Requirement All people who live in this home must be fully assessed by a suitably qualified person prior to admission. Previous timescale 30/09/07 remains unmet When medication is administered to people who live in this home, it must be clearly recorded to ensure that people receive the correct levels of medication. Previous timescale 30/09/07 remains unmet Immediate requirement issued. People who live in this home must be protected by the appropriate safeguarding processes being followed at all times. Sufficient staffs that are appropriately trained must be on duty at all times to care for people in this home. People who live in this home must be protected by the homes recruitment policy. Immediate requirement issued. DS0000014887.V356853.R01.S.doc Timescale for action 28/02/08 2. OP9 13(2) 31/12/07 3. OP18 13(6) 18/01/08 4. OP27 18(1)(a) 30/01/08 5. OP29 19(1)(b) 31/12/07 Brook House Version 5.2 Page 25 6. OP31 9 7. OP35 13(6) 8. OP38 37(1) The care of the people in this home must be managed by an individual who can demonstrate their compliance with the Care Homes Regulations. People who live in this home must be protected by accurate records of personal financial transactions. Immediate requirement left. People living at Brook House must be protected by the appropriate reporting processes, both to CSCI and the Safeguarding team. 18/01/08 31/12/07 19/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations Staff should consider a system that allows the door bell to be heard in all areas of the home. Brook House DS0000014887.V356853.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Brook House DS0000014887.V356853.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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