Inspection on 06/05/08 for Brook House

This inspection was carried out on 6th May 2008.

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

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brook House 72 High Street Riseley Bedfordshire MK44 1DT Lead Inspector Mrs Louise Trainor Unannounced Inspection 6th May 2008 11:20 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.V361577.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.V361577.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.V361577.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. 13th February 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.V361577.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 0 star. This means the people who use this service experience poor 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 6th of May 2008 by Regulatory Inspectors Mrs Louise Trainor and Mrs Sally Snelson, between the hours of 11:20 and 15:45 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 four 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 four and a half hour inspection. We were extremely concerned, that this inspection has generated many requirements, which although had met compliance at the Random Inspection in January 2008, are repeated from the Key Inspection in December 2007, indicating a problem with sustainability of improvements. For this reason some short timescales have been issued, and failure to comply with these timescales will result in Enforcement action being instigated without further warning. As the inspection coincided with CSCI arranging a thematic probe around safeguarding we asked specific questions to the staff and the manager during the inspection. We would like to thank everyone involved for their support and assistance during this visit to the home. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service does what is required to satisfy the regulators, and has the right policies and procedures in place, however there is evidence that the practices relating to pre admission are not always consistent or well applied. No clear system for compliance with the administration, safekeeping and disposal of controlled drugs is in operation and some staff are unclear of what is required. Health care is reactive rather than proactive, and reviews and record keeping are insufficient to ensure the safety of the people who live in this home. The home tries to be flexible and attempts to provide a service that is as individual as possible, however, although some residents are given choices, this process could be improved to include those with more severe disabilities. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 7 There are safeguarding policies and procedures in place, and staff have attended training, however there maybe an ‘it could not happen here’ mentality within this service which stops some referrals being made. Lack of records indicates that the manager continues to lack understanding and control of some of the main components involved in the running of this home and the protection of the people who live there. 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.V361577.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.V361577.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, 6 Quality in this outcome area is adequate. The service does what is required to satisfy the regulators, and has the right policies and procedures in place, however there is evidence that the pre admission practices are not always consistent or well applied. This judgement has been made using available 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 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. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 10 We picked the contracts of six residents, who had been admitted to this home since our last inspection, at random to check. Four were in place, signed and dated appropriately, however the manager was waiting for two to be returned. The files of two of the new residents were chosen by the inspector for inspection. Pre admission assessments had been carried out on both of these people prior to admission. However these were very brief, and lacked detail, this was similarly highlighted at the Random Inspection in January 2008, and has clearly not been addressed. This home does not provide an Intermediate Care Service. Brook House DS0000014887.V361577.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, 11 Quality in this outcome area is poor. No clear system for compliance with the administration, safekeeping and disposal of controlled drugs is in operation and staff are unclear of what is required. Health care is reactive rather than proactive, and reviews and record keeping is insufficient to ensure the safety of the people who live in this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of four residents were examined during this inspection. Two of these residents had been admitted since the previous inspection. Both had pre admission assessments in place however there was very limited information recorded in either. One was not signed or dated, and there was no photograph identification for either. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 12 One file identified that the individual was ‘totally independent’ with ‘no problems’, however records also indicated that they had a diagnosis of Dementia, poor short term memory and anxiety problems. This was rather contradictory. There were no detailed care plans in place, however a risk assessment had been carried out and reviewed six weeks later. Details of activities for this person were completed, however out of fifteen entries, five were for ‘hair’ and two were for ‘visitors’. Therefore realistically, this person’s activities for a two month period, consisted of, two bingo sessions, two church services, and a walk around the village. Another resident had a diagnosis of Dementia and panic attacks. They had been assessed as requiring ‘supervision of one carer for washing and dressing’. However there were no further instructions to guide care staff as to what supervision this may be, or how much this person was able to do for themselves. We watch another resident come down the stairs backwards carrying a Zimmer frame, when we checked his file, this was not reflected in his care plan, nor was it risk assessed despite the fact that this is his normal method of transfer down the stairs. Medication had caused us serious concerns at the previous Key Inspection in December 2007. Since this time The Commission For Social Care (CSCI) Pharmacy inspector had visited the home, and generally requirements issued at this time were complied with. We were therefore disappointed to find new issues relating to medication practices occurring. Medication Administration Record (MAR) sheets were tidy, and there were individual’s photographs and personal information attached to each. There was a list of staff sample signatures, and a list of omission codes also in the MAR sheet file. The MAR sheets of eight residents were examined in detail. Generally these were being completed with administration or omission codes appropriately and the reverse of the charts was being completed as required, however the receipt of stocks was not always being recorded appropriately, therefore making reconciliation difficult. Two residents in the home self-administer prescribed creams, there were risk assessments in place for this, however on visiting these individual’s rooms, the creams were not locked away. In one room there was also a bottle of Simple Linctus that had been left by the bed. This could have been accessed and ingested by anyone, as this bedroom was not locked. There was a new Controlled Drugs (CD) book in place, that had been appropriately completed, and a new controlled drugs cabinet had been fitted to meet with regulations. Unfortunately the inspection revealed that someone had removed, four vials of Morphine Sulphate, which was no longer required, from the Controlled Drugs (CD) cupboard into a filing cabinet for ‘safety’. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 13 On inspecting the contents of the CD cupboard we became aware that these drugs were missing. Neither the manager nor her deputy were able to locate them, and after forty-five minutes of hunting for these drugs they decided to contact an off duty carer. She advised them that she had locked them in a filing cabinet so that no one gave them by mistake. The manager advised her that they needed to be returned to the CD cupboard. The carer came in and did this immediately. An immediate requirement was issued relating to medication procedures. During this inspection we were made aware that regular medication orders are delivered to the home for collection by local villagers who are unable to get to the surgery themselves, this included staff. Although we appreciate this is custom and practise in this home, and it is done out of duty to the community, it is a matter which we need to discuss with the pharmacy inspector to ensure that the home are using the correct procedures to safeguard themselves during this process. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 14 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. The home tries to be flexible and attempts to provide a service that is as individual as possible, however, although some residents are given choices, this process could be improved to include those with more severe disabilities. This judgement has been made using available evidence including a visit to this service. 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 staff this unit, and their meals are prepared in the home and carried over from one building to another. This practice should be risk assessed for health and safety reasons. On the day of this inspection there was little evidence of any ongoing organised activities in the home, however some residents were seen busying themselves with a purpose. One resident was checking to see if the laundry in the garden was dry. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 15 During the afternoon the only evidence of any activities, was two ladies knitting in one of the lounges. In the other, residents were just sitting staring into space, and although the television was on, no one appeared to be watching it. There were very limited interactions from the staff. There was a menu board in place in the dining area. On the day of the inspection, there was a choice of ‘faggots’ or savoury mince for the main course. This did not give a particularly varied choice, as both dishes are made up of similar mincemeat ingredients. The manager advised us that the choice was as it was, because the cook had forgotten to take the sausages out of the freezer, the alternative should have been ‘toad in the hole’. The meals were plated up and served without a choice being offered at point of service either visually or verbally. Staff did however indicate that a verbal choice had been offered earlier in the day, although it was unlikely many of these residents would understand or remember this. The choice of desserts on the day of the inspection was, cake and custard or fruit jelly with ice cream, however everyone appeared to be being given pineapple and custard. The mealtime observations revealed there were no condiments on the tables for any of the residents, one gentleman had to ask for salt and pepper, and everyone was issued with plastic beakers to drink from. Although we appreciate that for some residents this is appropriate, for others it is not, and there is no reason why glasses and crockery should not be used. There were eighteen residents having dinner in the home. One lady chose to have hers in her room however the majority of residents were seated in the two dining areas. There were two care staff and a senior carer on duty across dinnertime to serve the meals and assist those who required help. Ten of the more independent residents were having their dinner in the ‘lounge dining’ area. There was very limited input from staff, and the meal passed almost in silence with very little conversation at all amongst the diners, with the exception of a request for salt from one person, and a comment from another that there was not enough salt in the food. There was no ‘social feel’ to this mealtime. Visitors are welcome in this home at any time, and although there were some visitors present during the earlier part of the inspection, we did not have the opportunity to talk with them. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. There are safeguarding policies and procedures in place, and staff have attended training, however there maybe an ‘it could not happen here’ mentality within this service which stops some referrals being made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints file was inspected during this visit. There had been three complaints submitted to the home this year. Evidence indicated that these had all been documented and investigated appropriately. One complaint was received from a family member who had concerns that there loved one was not wearing their hearing aid as they should. Records showed that staff had all been made aware of this issue and how it should be managed, and the complainant was advised of what action had been taken to resolve the problem. Another was regarding two missing nightdresses, both of which were found. The third was regarding someone’s personal hygiene, where records proved that although some bathing had taken place, this individual regularly refused assistance with personal care. There was no care plan to indicate how this problem was managed by staff. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 17 Records show that the majority of staff have undertaken safeguarding training since January 2008, and those asked about this process, both at this inspection and at the Random Inspection earlier this year were able to demonstrate their understanding of the process, and when incidents should be reported. However we were concerned that a medication error, which was revealed through the staff file inspections had not been reported as a safeguarding issue, nor was there documentation to identify any management or review process. As described elsewhere in this report, the records of individual’s personal expenditures were again not always up to date, and discrepancies were found. The fact that this problem has reoccurred indicates that not all staff appreciate the importance of keeping these records accurately, this indicates that, as staff have told us previously, they do not believe that anyone working in the home is capable of abusing the residents. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This home provides a clean, comfortable and homely environment for the people who live here. This judgement has been made using available 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. On the day of the inspection the sun was shining and laundry was hanging out to dry. It was heart warming to see residents accompanying staff to check if Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 19 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. At the previous Key Inspection in December 2007, 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. This matter has now been addressed and the doorbell can be heard throughout the home. 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. A number of the bedrooms had been decorated since our last visit. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This service recognises the importance of training and tries to deliver a programme that meets the National Minimum Standards. However the management of staff disciplinary matters needs to be clearly documented to ensure that people who use this service are protected at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff training matrix was examined, and indicated that since January 2008, mandatory training, which included; Moving and Handling, Health and Safety, Fire Safety, Infection Control, Food Hygiene, Safeguarding, Medication Administration, Dementia and Challenging Behaviour, had been attended by most staff, but not all. An external trainer, who previously worked for a large training company, is presently delivering the training to the home. This service is presently introducing an ‘Experimental Workshop’ for staff. The manager hopes that this will give staff some idea of what it is like to live with Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 21 some of the disabilities experienced by their residents. This will hopefully help them appreciate more fully the way in which they deliver care. The recruitment of staff was not examined in any depth during this inspection, as this had been inspected at the Random Inspection in January 2008 and the manager told us that no new employees had been recruited since this time. However the files of two staff members were examined. Both contained letters referring to disciplinary matters. One was referring to personal gross misconduct and the other to medication administration related matters. We were unable to find any documentary evidence to suggest how either of these matters had been managed or reviewed so that the cases could be closed. Nor was there any evidence to suggest that the issue relating to medication been reported to the safeguarding team. The manager informed us that reviews had been done verbally. This is not acceptable and we explained that serious matters such as those discussed should have clear records of all investigations and disciplinary steps taken, including a documented outcome. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is poor. Lack of records indicates that the manager continues to lack understanding and control of some of the main components involved in the running this home and the protection of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection, the registered manager was returning for her first day back following a three-week holiday, and was unaware of, and unable to explain or account for issues, such as medication storage, residents personal expenditure records and the management of staff disciplinary issues, which had given us concerns throughout this inspection. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 23 The home manages ‘personal allowance money’ for many of the people who live there. At the 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 this visit, indicating that the home have not learnt from previous requirements. When we began this particular area of inspection, the deputy manager informed us that there was £6.50 in a small plastic bag, in the box with the individual residents wallets. She advised us that this was to be refunded into someone’s account, however, at this point she was unsure whom it belonged to. The records of thirteen people’s accounts were examined. One persons record indicated that they had £46.04 funds remaining in their account, however there was only £35.04 present. Another person’s records indicated a balance of £136.21, but there was £138.21 present. Many accounts were in debit rather than credit, as they were waiting for records to be updated following a recent chiropody visit. We were unable to identify whose account the £6.50 should be refunded to. Again we stressed to the manager and her deputy that completing these financial records in retrospect of expenditure is not acceptable. We examined the supervision records for seventeen members of staff. All records identified that everyone had received at least two supervisions since October 2007. Although it is encouraging to see that supervision is taking place in this home, we were concerned that the two senior care staff in this home were doing all the supervision. Neither the manager or her deputy are involved in this process, and infact do not receive any supervision themselves. One of these senior staff has not had any training in supervision, and therefore it is questionable how effective this process is. One person’s records indicated in October 2007, that they ‘required hoist training’. There was no evidence to indicate that this had been done. We were also made aware that the two senior carers provide supervision for each other. Although we appreciate that there is a valuable place for ‘peer supervision’, we were concerned that a line manager was not supervising either of these staff, and where individual’s personal and practice issues should be being reviewed regularly, this was not happening. Accidents and incidents are being appropriately reported to The Commission for Social Care Inspection (CSCI) and other agencies as required. The manager informed us that Quality Assurance has not yet been addressed in the home this year. The relevant CSCI certificates are now appropriately displayed in the entrance hall of this home. Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 1 2 2 3 Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 12(1)(a) 12(3) Timescale for action The care requirements for people 30/06/08 who use this service must be clearly documented in individual care plans to ensure that care is delivered with continuity and in a way that they prefer. The people who live in this home must be protected by suitable arrangements for the recording, handling, safekeeping and safe administration of medicines received in to the home. Immediate requirement left. 3. OP12 16(2) The people who use this service must be offered activities that are delivered competently in order to provide them with appropriate stimulation People who use this service must be offered a choice of varied nutritious meals, which are suitably prepared to meet their needs. The care of the people in this home must be managed by an individual who can demonstrate DS0000014887.V361577.R01.S.doc Requirement 2. OP9 13(2) 11/05/08 30/06/08 4. OP15 16(2)(i) 12 (2) 31/05/08 5. OP31 9 31/05/08 Brook House Version 5.2 Page 26 a clear understanding of their responsibilities and control of all systems in the home that protect the people who live here. 6. 7. OP35 OP36 13(6) 18(2) People who live in this home must be protected by accurate personal expenditure records. Staff must receive a minimum of six supervision sessions a year from an appropriate supervisor. Accurate and up to date records must be completed in order to protect people who live in this home. This must include staff management issues. 31/05/08 30/06/08 8. OP37 17(3) 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brook House DS0000014887.V361577.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V361577.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!