CARE HOMES FOR OLDER PEOPLE
Brookdale View 1 Averil Street Newton Heath Manchester M40 1PD Lead Inspector
Geraldine Blow Unannounced 6 September 2005
th 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 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. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Brookdale View Address 1 Averil Street Newton Heath Manchester M40 1PD 0161 688 7600 0161 682 3004 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Healthcare Services Ltd Responsible Individual - Mr Philip Scott Laura Ann Riley Care home with nursing (N) 48 Category(ies) of Old age, not falling within any other category registration, with number (OP) (48) of places Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1 The home accommodates a maximum of 48 older people. 2 The maximum number of service users accommodated on the ground floor and requiring nursing care shall be 24. 3 Service users requiring personal care only are accommodated on the first floor. 4 Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes act 1984 issued on 8th October 2001. Date of last inspection 20 January 2005 Brief Description of the Service: Brookdale View Nursing Home provides accommodation for a maximum of 48 older people. The home is able to accommodate 24 older people assessed as requiring nursing care, on the ground floor and 24 older people assessed as requiring personal care only on the first floor. The premises are owned by Nursing Home Properties (NHP) PLC and are leased to Southern Cross Healthcare Limited. Mr Philip Scott is the responsible individual on behalf of Southern Cross. The home is situated in the Newton Heath area of Manchester close to a local market, shops, public houses and other social areas and amenities. The home was first registered with the Commission for Social Care Inspection (CSCI) on 30th July 2002. The home consistes of a large purpose built building set in its own grounds, which was shared by its sister home operating on the same site. Ample car parking faciliites are available. The home offered accommodation in 48 single, en-suite bedrooms. Accommodation for residents is provided on two floors accessed via a passenger lift and stairways. Each floor offers 2 lounges and one dinning room. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the course of 6 hours on Tuesday 6th September 2005. During the course of the inspection, time was spent talking to the manager, staff and residents to find out their views of the home. Time was spent examining records, documents, residents and staff files. A tour of the building was also conducted. Since the last inspection, in January 2005, the CSCI has not received any complaints. The home kept a record of any complaints made directly to them, which included details of the investigation and any action taken. The requirements from the previous inspection had been addressed and there was evidence that the manager was working hard to develop the service. During this inspection only a selection of the key National Minimum Standards were assessed. Therefore in order to gain a full picture of how the home meets the needs of residents, this report should be read with the previous and any future reports. What the service does well:
The home manager assessed prospective residents care needs before their admission to the home to ensure their needs can be met. Overnight stays or day long visits can be arranged so that the prospective resident can meet other residents, staff and get a feel for the home before they make a decision to move in. Equipment necessary for the prevention or treatment of pressure sores was viewed during the inspection. At the time of inspection the home did not have any residents with a pressure sore. The complaint policy was on display in the main reception area and included all the correct information. Several residents spoken to said they have never made a complaint. One resident said, “I have never made a complaint but I would go to “Laura” (the manager) or “Mary” (the senior carer) if I wanted to make a complaint. One resident did say that she had made a complaint because she did not want to go to bed at 10pm. This was discussed with the senior carer, of the unit, and the manager. The compliant had been addressed and the member of staff in question had been spoken to.
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 6 The standard of cleanliness throughout the home was high. One resident said, “the home and my bedroom are always kept very clean”. Another resident said, “the home is nice and clean”. In an attempt to create a homely atmosphere there were small tables in the hallways with candles and vases of flowers around the home. All of the bedrooms were single occupancy with en-suite facilities. Each bedroom had a suitable privacy lock fitted and all rooms had a lockable storage space. The bedrooms were nicely decorated and several had been personalised with resident’s belongings. Residents are given a choice of colour and decoration for their own room. The home appeared to treat the residents with respect and dignity. The manager said that residents get choice with regard to their daily lives. Unless it is detrimental to their care, the residents can go to bed and get up when they choose. The staff spoken to confirmed this. One resident said “ the staff are all nice”, another resident said “the staff do look after you and are nice”. The manager said that the home had an open visiting policy. All residents spoken to confirmed this. One resident said, “ visitors are made welcome and can come anytime they like, unless it is 6 o’clock in the morning”. Another resident said, “ my visitors are always made very welcome”. A small group of residents were seen sat outside, under the front porch, with a member of staff. They were observed to be chatting and laughing together. The home has a daily menu on display in the main reception area and each dining room has a menu sheet available. The menu offers a choice at each mealtime. One resident spoken to said, “you can’t grumble about the food”. However another resident did say, “the food is just OK”. What has improved since the last inspection?
The side of the home overlooks the local bowling green. The residents enjoy watching the bowling in the nice weather. So since the last inspection a patio area had been laid and new patio furniture has been bought for residents and relatives to use. Static gazebos had been erected to provide a shaded area. Unfortunately in some recent windy weather the gazebo frames had been broken but there were plans to replace these for next year The home employs 2 activity co-ordinators. Activities seem to be an area that the home is keen to further develop. Both units have an activity display board that advertises events, up to Christmas 2005, in an attractive laminated poster format. One resident spoken to said she had played bingo that morning and
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 7 really enjoyed it. Two other residents said they had taken part in a sponsored wheelchair push the week before. They said it was great fun and they really enjoyed it. One resident said she had gone round the shops on Sunday “and that was good”. The manager sent letters to residents relatives inviting them in to review the care plans. If the relatives were unable to attend, the manager then sent a letter informing them of any changes in care following the review. Since the last inspection 3 bedrooms have been redecorated and the water damage to the stairwell ceiling between the first and second floors had been repaired, as required in the last inspection. What they could do better:
The manager must make sure that staff have signed for everything that is given to residents on the medication sheets so that a full audit trail is available. The manager said that light snacks and drinks were available on request throughout the day and night. This was confirmed by the staff spoken to and the staff gave residents names and examples of this happening. However the residents spoken to appeared unaware of this. One resident said, “they would not make you a drink unless it was drink time”, another resident said, “ you can’t ask for a drink or something to eat just when you want”. Although she then said that she had never asked for anything because she had never wanted anything. The manager should ensure that residents are made aware of their right to request snacks and drinks in addition to the set times. One of the paving slabs on the patio area had been taken up. This must be urgently replaced as it could cause a trip hazard. The manager said she would get that done the next day. At the back of the home was a fenced off “skip area”. However the gate had been broken off and the broken metal gazebo poles and some garden rubbish had been left exposed. The gate must be replaced to ensure residents and visitors are not placed at risk. It is recommended that the carpet in the ground floor smoking lounge be replaced as it is showing signs of general wear and tear and has several cigarette burns in it. The hoists that are used to transfer residents who are unable to transfer on their own must be thoroughly cleaned. Some infection control recommendations have been made and the manager is required to contact the local primary care trust infection control nurse for further advice.
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 5 The home undertakes an assessment of prospective residents care needs prior to their admission. Relatives and friends are able to visit the home before making a decision to stay. EVIDENCE: Evidence was seen that prospective residents had a pre-admission assessment to ensure that the home could meet all of their assessed needs. The assessment included the involvement of the prospective resident, his/her representatives and any relevant professionals. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. Following the pre-admission assessment the manager confirms in writing to the prospective resident that the home is able/not able to meet their assessed needs. Prospective residents and or their representatives are encouraged to view the home and speak to staff. Usually the prospective resident is invited to stay for the whole day and overnight stays can be arranged on request. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 11 The home had a policy regarding trial stays and the first 6 weeks of a placement are considered as being a trial period. The home does accept emergency admissions and has a policy relating to this. Where possible a pre admission assessment is still undertaken. Where an emergency admission is necessary, the home would inform the resident and / or their representative of the home’s rules and routines etc within 48 hours of the admission. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 Overall the health and personal care needs of the residents appeared to be met at the home. However the plans of care must accurately reflect all the residents assessed needs. The system for recording all prescribed medicines needed some improvement to provide an accurate audit trail of medication. EVIDENCE: Residents care plans were not fully assessed during this inspection as the home was in the process of introducing new care plan formats. However, examples of current care plans were seen and found that information regarding a residents nutritional needs was insufficient and the manager needed to risk assess and gain consent for the use of the “bucket chair” as this chair constitutes a form of restraint. Evidence was seen of monthly reviews and the home kept a daily record of the care provided. A thorough inspection of the care plans will be conducted at the next inspection once the new system is fully implemented. The requirement from the last inspection that residents/representative are involved in the care planning process or if this is not possible the next of kin are notified of revisions to the plan of care had been met.
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 13 The home operated a named nurse system and this information was available to residents and relatives within the resident’s bedroom. All residents were registered with local General Practitioners and had access to visiting healthcare professionals e.g., Dietician, Chiropody, Dentistry and Ophthalmology. The home had a comprehensive corporate medication policy and procedures. Both drug trolleys were stored in the nurses’ office, which was kept locked when not in use. Both trolleys were secured to the wall. The drug fridge was situated within the nurses’ office. Temperatures had been recorded, however there were some gaps in recording. Evidence was seen that the fridge had recently been defrosted. On examination of the Medicine Administration Record (MAR) sheets it was noted that some prescribed medication e.g. creams had not been signed for. All prescribed medication must be signed for by the person administrating them to facilitate audits and to ensure that the records are clear and accurate. Inline with new legislation, from the 1st Aril 2005, the home employed the services of an independent company to dispose of pharmaceutical waste. The home does not see the prescriptions before they are dispensed, nor do they have a copy of the prescriptions to use as an up to date copy of each service users medication. Professional guidelines indicate that the home should see the prescriptions prior to dispensing and good practice indicates a copy of the prescription should be kept of these prescriptions. From observations made during the inspection and discussions with members of staff and residents it appeared that the nurses and care staff treated the residents with respect and dignity. The manager said that the preferred term of address would be documented on the front admission sheet. Medical examinations were carried out in the privacy of the resident’s bedroom. A pay phone was available for residents in the reception area of the home. However residents could have a private mobile phone on request. The home had a policy in respect of mail delivery and all residents received their mail unopened or it was passed unopened to relatives or representatives. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 & 15 Activities were available to residents. It appeared that residents were able to maintain contact with family/friends. Meals appeared to be nutritious and well balanced. EVIDENCE: The home employed 2 part time activity co-ordinators. Evidence was seen of regular activities. The manager verbally explained how residents are consulted regarding the activities provided. However there was no written evidence to support this. The home must keep a record of any consultation with residents regarding the programme of activities arranged by the home on their behalf. A social assessment is completed pre-admission and then again in more detail on admission to the home. A record of social activities attended is recorded in each residents file. The home operated an open visiting policy and visitors could be received in private or in any of the communal areas. The residents spoken to confirmed this. Visiting was only restricted if requested by a resident or their advocate. Any restriction was formally recorded and communicated to all persons concerned.
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 15 The menu inspected had been developed on a 4-week rota system. The meals offered appeared nutritious and wholesome. A menu is on display in the main reception and in each dining room. On the day of inspection the lunch observed was chicken nuggets with peas or a bacon barm. However the menu stated chicken grill. It is recommended that the menu accurately reflect the meal available. Staff were observed giving assistance with feeding discreetly and sensitively. There were no specific religious or cultural dietary needs at the time of inspection. The manager reported that these would be discussed at the preadmission assessment. Alternative meals are available at each mealtime or any other reasonable request such as sandwiches, soup or cheese on toast etc. would be provided. Residents appeared unaware that they could request drinks and snacks outside of the designated meal and drink times. It is recommended that the residents be informed of this. The home provided an attractive dinning room on each floor and most residents were encouraged to have their meals there. However residents were able to use other areas of the home on request. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The complaints procedure was on display and residents appeared to know how to make a complaint. The home’s policies and procedures served to protect the residents from abuse. EVIDENCE: The home had the complaint procedure on display in the main reception area, which was seen to include all the relevant information. The home maintained a complaint file, which contained details of the complaint, staff statements, the actions taken and the outcomes. Since the last inspection the home had received one compliant, which was still under investigation. The residents spoken to said they would complain to the manager or unit manager if they had any concerns. The home had corporate policies relevant to vulnerable adult protection including whistle blowing. The homes’ own policies were in line with the multiagency policy and the Department of Health (DOH) Guidance, “No Secrets.” The manager was advised to obtain a copy of the Manchester’s Multi-agency Policy for the Protection of Vulnerable Adults from Abuse and a copy of the DOH “No Secrets” Guidance. The manager said that all staff had received training on the actions to be taken in the event of an allegation of abuse in 2005. This was confirmed by 2 of the staff members spoken to. However one senior carer said she had not received
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 17 any training, although she correctly described the actions to be taken and said that the policy was on the unit for reference. The home had a policy precluding staff from accepting gifts or being involved in the making of or benefiting fro m residents wills. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24 & 26 The homes environment was clean and comfortable. However a number of risks to residents’ health and safety were identified during the inspection, which must be attended to, to prevent injury. There were some concerns relating to infection control. EVIDENCE: The location and layout of the home was suitable for its stated purpose. On the day of inspection the home was clean, tidy and free from offensive odours. There was some damage to the middle stairwell and the manger said that she was awaiting the plasters to repair it. The home employs a gardener and a handyperson. The handyperson had specific responsibility for environmental health and safety records were held. The homes garden was well maintained and accessible to residents. However it was noted that one of the patio paving slabs had been removed and was leaning against the wall. This is a potential trip hazard and must be replaced
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 19 as a matter of some urgency. In addition the missing gate to the ‘skip’ storage area must be replaced. The carpet in the smoking lounge on the ground floor was showing signs of “wear and tear” and had several cigarettes burs. It is recommended that this be replaced. Also one wall of the lounge was seen to have a large dirty mark on it. The manager said this was because they had recently removed a large sideboard, which had left the mark. The home had adequate bathing facilities and these along with communal WC’s were clearly marked. It was noted that 2 hoists were being stored in bathroom 31. It was requested that these be removed. In addition the waste bin in toilet 29 had the lid missing. The doors to the sluice areas had electronic digital locks, which were keypad operated. It was noted during a tour of the building that both sluice doors were not locked. The home had corporate policies relating to infection and the laundry was sited on the second floor of the home, which did not offer any resident accommodation. The laundry was not viewed on this occasion. A number of concerns relating to infection control were identified during the inspection. It was noted that the hoists were generally dirty and the standing hoist had encrusted food on the handle which residents grab hold of in order to aid the stand. These must be thoroughly cleaned. It has been recommended, in accordance with infection control guidance that: 1. Personal Protective Equipment (PPE), which includes gloves, aprons and wipes should be made available in residents’ bedrooms, toilets and bathrooms to facilitate the management of personal care. 2. The home should ensure equipment is cleaned in between resident use. 3. The home should make equipment wipes available in the nurses’ office, sluices and next to hoists to facilitate cleaning. 4. To prevent the risk of cross infection an individual sling should be provided for each resident requiring the use of the hoist. 5.The home should develop and implement a policy on the use of wipes. 6. The home should consider purchasing individual hand held alcohol gel for staff. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 20 The manager must contact the infection control nurse for up to date legislation and professional guidance regarding the above recommendations and arrange training. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 The numbers and skill mix of staff appeared to be sufficient to meet the needs of the residents. The homes recruitment policies and procedures appeared to promote the safety and wellbeing of the residents. However evidence of a satisfactory enhanced CRB disclosure and a recent photograph of all staff must be kept on file. EVIDENCE: At the time of the inspection the home accommodated 34 residents i.e. 11 residents assessed as requiring nursing care and 23 residents assessed as requiring personal care only. The numbers and skill mix of the staff, at the time of inspection appeared to be sufficient to meet the needs of the number of residents accommodated. The home employed 17 care staff, 3 of those had achieved NVQ level 2, 2 were currently undertaking the training and 2 were waiting to start it. The remaining 10 care staff were oversees adaptations nurses who were all currently working through their 12 months experience before undertaking their adaptation training. The sample of staff files inspected contained all the information and documents listed in Schedule 2 of the Care Home Regulations 2001, with the exception of one file that was missing a photograph. The staff member had recently been employed and the manager stated that the photograph had been requested.
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 22 One further file had evidence of a POVA first but did not contain evidence that the enhanced CRB disclosure had been received. This information must be received prior to any member of staff working unsupervised. The manager requested the information to be sent directly to her. The home operated a three-months probationary period for all appointments. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the standards in this section were assessed on this occasion. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 x 2 x x 3 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x x Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 25 No Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement The responsible individual must ensure that the plans of care accuratley reflect the residents assessed needs and sets out in detail the action which needs to be taken by care staff The use of restraints such as the Bucket Chair must be risk assessed and consent be obtained for its use. The tempurature of the drug fridge must be monitored daily . The normal range is between 2 and 8 degrees centrigrade. All prescribed medication must be signed for by the person administrating them. 1. Prescriptions must be seen and checked prior to sending them to the pharmacy. 2. An up to date record of service users medication must be maintained by the home Evidence must be provided that residents are consulted about the programme of activities arranged by the home Timescale for action 31/10/05 2. 7 13 31/10/05 3. 9 13 31/10/05 4. 5. 9 9 13 13 31/10/05 31/10/05 6. 12 16 31/10/05 Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 26 7. 18 13 8. 19 13 The responsible individual must ensure that all staff receive training in the action to be taken in the event of an allegation of abuse. To eliminate any unnecessary risk to the health or safety of residents: 1. The patio concrete slab to the side of the home must be relaid. 2. The gate to the skip storage area must be replaced. 3. The damage to the middle stairwell must be repaired. 1. Equipment, such as hoists, must not be stored in any of the bathrooms. 2. All waste bins must have a lid in situ. The sluices must be kept locked when not in use to ensure that any unnecessary risk to the health or safety of residents are as far as possible eliminated 1. The responsible individual must seek advice from the infection control nurse for up to date legislation and professional guidence. 3. Infection control training must be arranaged for the manager and unit managers. 2. All hoists must be thoroughly cleaned to prevent the risk of cross infection. 1.The responsible individual must ensure that evidence of a satisfactory Enhanced CRB Disclosure is held on all staff files.
F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc 31/10/05 13/9/05 9. 21 13 13/9/05 10. 21 13 13/9/05 11. 26 13 13/9/05 12. 29 19 13/9/05 Brookdale View Version 1.40 Page 27 2.The responsible individual must ensure the requested photograph of the newly appointed staff member is held on file in accordance with Schedlue 2 of The Care Homes Regulatins 2001. 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 15 Good Practice Recommendations 1. It is recommended that the daily menu accuratley reflect the meal available. 2.It is recommended that residents are made aware of their right to request snacks /drinks at any time. It is recommended that the manager obtain a copy of the Manchester’s Multi-agency Policy for the Protection of Vulnerable Adults from Abuse and a copy of the DOH “No Secrets” Guidance, 1. It is recommended the carpet in the smoking lounge on the ground floor is replaced. 2. It is recommended that the wall with the dirty mark on in the ground floor smoking lounge is removed or redecorated. It is recommended that: 1. Personal Protective Equipment (PPE), which includes gloves, aprons and wipes should be made available in residents’ bedrooms, toilets and bathrooms to facilitate the management of personal care. 2. The home should ensure equipment is cleaned in between each use. 3. The home should make equipment wipes available in the nurses room, sluices and next to hoists. 4. To prevent the risk of cross infection an individual sling should be provided for each resident requiring the use of the hoist.
Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 28 2. 18 3. 19 4. 26 5. The home should consider purchasing individual hand held alcohol gel for staff. 6. The home should develop and implement a policy to include the above. Brookdale View F55 F05 s21536 Brookdale View V247871 D060905 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection 9th Floor, Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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