Inspection on 18/09/07 for Brook House

This inspection was carried out on 18th September 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 18/12/07

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 Louise Trainor Key Unannounced Inspection 18th September 2007 08:00 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.V346382.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.V346382.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.V346382.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. 7th November 2006 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 490.00 per week. Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulatory Inspector Mrs Louise Trainor carried out this was a Key Inspection on the 18th of September 2007 between the hours of 08:00 and 16:45 hours. It focused on all outcome areas for the people who live in this home, in particular reviewing the homes compliance with requirements made at the previous inspection in November 2006. As this was the first visit to this home for this inspector, a full tour of the premises, internal and external was carried out. Including the day centre annex. The manager and deputy manager, made themselves available to assist and support throughout the day. During the inspection, the personal files and documentation of three of the people who use this service were examined, and four people were interviewed informally. Four staff files were picked at random by the inspector to examine and four members of care staff spent time with the inspector discussing their roles and their experiences in the home. Documentation relating to: staff training and supervision, quality assurance, complaints and medication administration were also examined, and short periods of observation of care practices were carried out during this eight and a half hour inspection. Nine ‘Have your say about…..’ questionnaires had been completed by the people who live in this home and returned to the inspector prior to this inspection. Information from these was included in this report. The inspector would like to thank the manager and all those involved for their assistance and support throughout this visit. What the service does well: This home provides a clean, comfortable and homely environment for the people who live here. Observations of care throughout the day, and discussions with the people who live in this home, indicated that relationships between staff and residents are familiar and respectful. There are a wide variety of activities available in this home, and individual people who use this service are encouraged to pursue personal interests within the local community. Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 6 Menus are varied and appealing offering a nutritionally balanced diet to the people who live in this home. The atmosphere during the lunchtime meal appeared relaxed and unhurried and overall an enjoyable social event for everyone who was present. There had been eight complaints documented since the previous inspection. These were clearly recorded, although all appeared to have been verbal complaints. This indicated that all matters are taken seriously and addressed appropriately. The home manages ‘spending money’ for many of the people who live there. The records for five individual’s accounts were inspected. All records balanced correctly with funds, and receipts were present for all purchases. What has improved since the last inspection? What they could do better: There is 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. Some people who live in this home do not have signed contracts in place. Initial care plans had been completed for each individual on admission, however there was limited evidence to indicate that reviews are carried out regularly. There were some risk assessments in place for moving and handling, and nutrition. However on two files seen by the inspector, the nutrition risk assessments had scores indicating a high risk, but there was no care plan in place to reflect how these risks were being managed. The systems in place for administering medication to people who live in this home are insufficient to ensure they are protected at all times. The privacy for some of the people living in the home was of concern to the inspector. When looking round the home, the inspector visited one bedroom of Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 7 a male service user and found that there was an adjoining door into a female service users bedroom. It was evident that not all staff had a full understanding of safeguarding procedures; therefore the people who use this service may not always be protected. The home has policies and procedures in place, however systems for reporting incidents within the home need reviewing to ensure service users’ health, safety and welfare are promoted and protected at all times. Formal supervision records for staff were very limited. The manager informed the inspector that not all staff presently receives regular supervision, and this is a process that requires her attention. 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.V346382.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.V346382.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, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is 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: The files of three people who live in this home were inspected. There was an initial assessment and care plan in place for each individual, however these did not identify a date prior to the admission date for completion. Two of these individuals did not have signed, completed contracts. The deputy manager said that they had been sent out, but had not yet been signed and returned. The admission date of one was 08/06/07 and the other was 18/05/07, therefore both had been in the home for more than three months. This exceeded the eight- week probationary period outlined in the Statement Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 10 of Purpose, but they still had no contracts in place. The third did have a signed contract however this did not contain specific details of the individual’s fees. 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. However there is no evidence of the range of fees charged for living in this home in either document, however details of fees are issued on a separate sheet which is enclosed with all documents sent to prospective service users and enclosed with their contracts. Nine completed ‘Have your say about……..’ questionnaires were completed and returned to the commission prior to the inspection. Of these only two indicated they had received information about the home prior to admission. Two said a family member had received this on their behalf, three had not received anything and two were unable to answer. Brook House DS0000014887.V346382.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. An initial care plan had been completed for each individual on admission, however there was limited evidence that reviews are carried out regularly, so that changing needs may not be met efficiently. The systems in place for administering medication to people who live in this home are insufficient to ensure they are protected at all times. EVIDENCE: Each service user had an initial assessment and care plan in place. However these contained limited information relating to the individuals wishes and preferences, and directions for care delivery were minimal. Review dates were written on the reverse of the care plan, but simply consisted of a date. There were no comments included, and no evidence to indicate changing needs were being addressed. According to one gentleman’s care plan he had had no changes in needs since 2005. Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 12 Some files had short term care plans in place, however these had not been updated and reviewed. Therefore any improvement or deterioration in their condition was not being clearly recorded and addressed. There were some risk assessments in place for moving and handling, and nutrition. However on two files seen by the inspector, the nutrition risk assessments had scores indicating a high risk, but there was no care plan in place to reflect how these risks were being managed. The file containing the Medication Administration Record (MAR) sheets, and the medication stocks for individuals were examined during this inspection. The medication file contained a sheet for each individual living in the home, which was attached to their Medication Administration Record (MAR) sheet. This included; a photograph of the individual, their name, their room number, date of admission, date of birth and their allocated key worker. There was no evidence of a staff signature sample list present in the file, nor was there any details of allergies noted. Generally MAR sheets had been completed correctly, however there were one or two missing signatures on the charts, and when stocks were checked, the medication was not in the blister packs for the corresponding dates indicating that some of the staff are not always following the administration procedures correctly. Some medication had been prescribed as a variable dose. Staff are not recording what dosage has been administered on the MAR sheet, therefore reconciliation is impossible and it is unclear how much medication some individuals have been given. When asked about controlled drugs in the home. The deputy manager presented the inspector with a small red cash box. This contained the homes ‘controlled drugs’. This method of storage is unacceptable. The inspector advised the deputy manager to seek appropriate guidance on this matter. Whilst visiting the resident’s bedrooms, the inspector found a tub of ‘sudocream’, which had an expiry date of 01/07 on it. Another tub of cream had a large yellow label stuck round it with an individuals name written on it in marker pen. This was covering the whole of the original label including expiry date. Observations of care throughout the day, and discussions with the people who live in this home, indicated that relationships between staff and residents are familiar and respectful. However privacy for some people was of concern to the inspector. When looking round the home, the inspector visited one bedroom of a male service user and found that there was an adjoining door into a female service users bedroom. This was not locked, therefore giving direct open access from one room to another. Discussions with the manager identified this as a fire door, however the privacy of the people who live in these rooms must be addressed. Brook House DS0000014887.V346382.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. 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 are varied and appealing offering a nutritionally balanced diet to the people who live in this home. 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. One of the people who lives in the home, spoke to the inspector about his social life, this included regular trips to the over 60 s club in the village, sessions in the day centre as well as in the home. He said. “I like it here, I have more friends here than I ‘ve ever had all my life”. He added. “I do everything I wish, and do most things for myself”. Outcomes for this person were clearly very good. Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 14 On the day of the inspection there was an activity worker, who works three mornings each week, preparing for an art session in the main house as well as activities being organised in the annex. Menus were varied and appealing offering choices to suit all tastes. On the day of the inspection there was a choice of sausage casserole or home made salmon fish cakes with fresh vegetables, however one service user informed the inspector he was having toad in the hole as it was his favourite. He also talked of how much he enjoyed the salads that the chef prepared on request. The atmosphere during the lunchtime meal appeared relaxed and unhurried and overall an enjoyable social event for everyone who was present. All of the questionnaires completed by the people who live here and returned to the commission, indicated that the food was of a high standard. One wrote. “My mother used to cry when I wouldn’t eat, but here I always eat”. Although this comment may have been written by someone who was confused, it was still a clear indication that they enjoyed the food in the home. Brook House DS0000014887.V346382.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. It was evident that not all staff had a full understanding of safeguarding procedures; therefore the people who use this service may not always be protected. EVIDENCE: The inspector viewed the complaints file. There had been eight complaints documented since the previous inspection. These were clearly recorded, although all appeared to have been verbal complaints. This indicated that all matters are taken seriously and addressed appropriately. Three of the complaints had been about the cleanliness of individual’s rooms and two were about the temperature of the bedrooms. The majority of these issues were dealt with immediately and did not have a written response. Three had clear written responses. One person in the home that talked to the inspector was very happy with the care he received and indicated that although he has never had reason to complain, he would know who to speak to if the need arose. All staff have recently received training relating to safeguarding the people who live in this home. However the level of understanding by some of the staff concerned the inspector. Although most of the staff were able to discuss what behaviours may constitute abuse. Some believed that any incident of Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 16 aggression towards staff from the residents should be reported to the adult protection team. All senior staff including the manager and the deputy manager discussed how they would thoroughly investigate any alleged incidents. This indicates that although the training has given staff an insight in how to recognise safeguarding issues, it has not given accurate information relating to the reporting processes. The homes local policy that is entitled ‘POVA’ is very brief, and states. “Form AP1 and AP2 will be filled out and sent to the appropriate authority who will make the decision as to proceed or not”. This is insufficient and needs to be more specific and directive. Brook House DS0000014887.V346382.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, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is adequate. 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. The communal lounge 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. There are four bedrooms on the ground floor and the remainder are on the first floor accessible by stairs. Although there is a stair lift, there is no shaft lift in Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 18 the building; therefore this could cause some difficulty for service users with physical disabilities (PD). There was a sign at the foot of the stairs, warning service users not to touch the rail of the stair lift, which appears to have ‘exposed tracking. This was a little concerning, as many of the service users are confused and have dementia (DE), and would be unlikely to understand this notice. The deputy manager told the inspector this would not cause them injury, would just result in getting oily hands. The inspector did test this theory, which did result in sticky, black fingers from the oil. This matter does require some attention. The stair lift has been discussed with the engineers, and confirmed this conforms with British Safety Standards. 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.V346382.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 adequate. This judgement has been made using available evidence including a visit to this service. The systems for ensuring that all staff have mandatory training immediately they commence employment, are insufficient to ensure that the people who use this service are protected at all times. EVIDENCE: The staff team in this home appear very dedicated. Many live in this small village and have worked in this home for many years. The number of staff on duty appears sufficient, however discussion with some of the staff revealed that if staff are sick, they are not replaced, and the team are expected to work short rather than using agency. The deputy manager stated that there are four staff on duty in the morning, three in the afternoon and two at night. Staffing rotas for August that were inspected, confirmed that this was the case, and there was no evidence of shortfalls. The training records indicate that the staff in this home attends mandatory training as required. This includes; moving and handling, safeguarding, food hygiene and infection control. A requirement from the previous inspection identified that staff needed training in the management of challenging behaviour, and further training regarding safeguarding procedures. Most of the staff have now completed these as required, however their understanding of Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 20 safeguarding procedures remains somewhat confused. This has been identified in more depth elsewhere in this report. Four staff files were chosen at random by the inspector to examine. These files were very disorganised, making it very difficult to locate the required documents for each staff member. Three of the four staff had been working in the home for many years and their Criminal Records Clearances’ (CRB) were dated February 2003. This was discussed with the manager who was advised to seek advice on renewal of these documents. The fourth member of staff had only been in post a short time, and although the CRB for this person could not be located during the inspection, it was later sent to the inspector as confirmation that it had been done. There were various forms of identification in the files, however not all had clear photographic ID present. The newest member of the team has only been in post since the end of July this year, and although she was able to talk about her two- week induction period, it was concerning that she had not yet completed any of her mandatory training. Brook House DS0000014887.V346382.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. The home has policies and procedures in place, however systems for reporting incidents within the home need reviewing to ensure service users’ health, safety and welfare are promoted and protected at all times. EVIDENCE: The manager of this home has worked here for approximately twenty years. She leads a committed team of staff, many of who have also worked in the home for many years. All staff that spoke to the inspector indicated that felt well supported and were happy in their jobs. However formal supervision records for staff were very limited. The manager informed the inspector that Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 22 not all staff presently receives regular supervision, and this is a process that requires her attention. The Responsible Individual to the home undertakes visits on a very regular basis, at least once a week, and accordance with Regulation 26. Reports are submitted monthly to the Commission for Social Care Inspection, and show that support is available to the management at the home. The home manages ‘spending money’ for many of the people who live there. The records for five individual’s accounts were inspected. All records balanced correctly with funds, and receipts were present for all purchases, however the receipts for money withdrawn for hairdressing were not signed, and there were no receipts in place to correspond with money taken from accounts for chiropody treatment. The inspector was also concerned that there were two unopened envelopes with one resident’s name on them. A family member had brought them in, and they had a sum of money written on them. This sum had been entered onto the account details, without the envelope being opened and the amount checked. The accident book was inspected for the month of August 2007. Seven falls had been reported in the accident book. Four of these seven falls had not been witnessed. None of these falls had been reported to the Commission for Social Care Inspection (CSCI) as a regulation 37 notification, and none had been reported through the safeguarding process. Neither the manager nor the deputy manager was aware that these were reportable incidents. Brook House DS0000014887.V346382.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 Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 1 1 2 X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 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 1 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 1 1 Brook House DS0000014887.V346382.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 OP2 Regulation 5(1)(b) Requirement Timescale for action 30/09/07 2. OP3 14(1)(a) 3. OP7 15(1)a People who live in this home must all have a signed contract of terms and conditions that includes information relating to their fees. All people who live in this home 30/09/07 must be fully assessed by a suitably qualified person prior to admission. Care Plans must be reviewed 30/09/07 monthly and alongside daily notes must provide sufficient information to establish the current wellbeing of all residents. (Previous requirement timescale 31/12/06 not met). 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. People who use this service must not have access to out of date creams. The people who use this service DS0000014887.V346382.R01.S.doc 4. OP9 13(2) 30/09/07 5. OP9 12(4) 30/09/07 6. OP18 13(6) 30/09/07 Page 25 Brook House Version 5.2 must be care for by staff who have a clear understanding of the reporting processes relating to safeguarding issues. 7. 8. OP36 OP37 18(2) 17 People who live in this home 30/09/07 must be cared for by staff who are appropriately supervised. All records relating to this home 30/09/07 and the people living there must be kept securely and reviewed appropriately. People living at Brook House 30/09/07 must be protected by the regulation 37 notification process being followed by the management of this home. 9. OP38 37(1) 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. 2. 3. Refer to Standard OP10 OP19 OP29 Good Practice Recommendations The home should consider some form of safe security for the door adjoining two bedrooms. The home should consider some form of guard for the stair rail. The manager should consider a more organised filing system for staff records. Brook House DS0000014887.V346382.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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.V346382.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!