Inspection on 11/09/07 for Brooke House

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brooke House 22/01/09

Brooke House 26/07/06

Brooke House 07/03/06

Brooke House 21/07/05

Brooke House 31/01/05

Brooke House 23/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Brooke House Brooke Gardens The Street, Brooke Norwich Norfolk NR15 1JH Lead Inspector Hilary Shephard Unannounced Inspection 11th September 2007 09:15 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 Brooke House DS0000049956.V350685.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. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooke House Address Brooke Gardens The Street, Brooke Norwich Norfolk NR15 1JH 01508 558359 01508 558376 tracey@kingsleycarehomes.com 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) Regal Healthcare Properties Ltd Mrs Tracy Fairhead Care Home 35 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (20) of places Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 Brief Description of the Service: Brooke House is a large Edwardian style house situated in the quiet village of Brooke just south of Norwich. The home is a large property with rooms on the ground and first floors to provide residential accommodation for up to 35 older people. The access to the property is via a long gravel drive that leads to a parking area at the front of the building. The grounds are substantial and well maintained providing nice views from all aspects. The home also provides a small unit called Brookfields accommodating people who have dementia. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers care outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgments for each outcome group. A total of 5 requirements were made as a result of this inspection. What the service does well: Prospective residents benefit from having their care needs assessed before admission by a competent person. The majority of able-bodied residents are able to pursue a lifestyle of their choosing. The food continues to be good and residents in the main house enjoy a very pleasant dining experience. The main part of the home offers residents a good standard of clean, wellmaintained accommodation in a pleasant and peaceful location. Communal areas of the main house are spacious and open out onto a terrace with views of the surrounding countryside. With the exception of one couple who have been sharing for some years all rooms are single occupancy with en suite facilities. There is a separate unit built to accommodate people with dementia. The manager has remained in post for over a year now and provides a good standard of management. Concerns are managed appropriately and professionally. Staff are provided in sufficient quantities to meet the care needs of the residents. Staff are also provided with an induction and mentoring programme that helps them develop their care skills. Staff whose first language is not English are provided with English lessons. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 6 Residents are involved in assessing the quality of the service they receive. A survey is regularly carried out and residents have an opportunity to air their views. The provider completes a useful and informative report with the findings from these surveys. What has improved since the last inspection? What they could do better: Residents with significant care needs would benefit from having more detailed and informative care records. Residents who have dementia would benefit from staff developing a more person-focussed approach to their care. Care records should also reflect residents care needs from a more person-focused viewpoint. Residents who are prescribed medication to be taken as required for behaviour that challenges should have a detailed plan that justifies the administration of these medicines. Residents who are less able and who are cognitively impaired would benefit from staff having a better understanding of how to engage with them and provide them with meaningful occupation. Residents would benefit from staff developing a better understanding of good dementia care practice. Staff also need to develop a better awareness of how they respect residents dignity. Residents well-being would be improved if the garden and layout and design of the Brookfields unit was accessible and developed to meet their specific dementia care needs. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 7 Recruitment practices regarding the obtaining of references from staff family members should cease as this practice is not acceptable. Residents health should not be compromised by misuse of bedrails therefore, any resident who needs bedrails should have a thorough and robust risk assessment completed. 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. Brooke House DS0000049956.V350685.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 Brooke House DS0000049956.V350685.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): 3 People who use the service experience good quality outcomes in this area. Residents’ benefit from being able to visit the home and from having their care needs assessed before they are admitted. This enables the manager to be sure staff are able to meet the residents needs and for residents to make an informed choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous inspection carried out in July 2006 found the manager using a detailed assessment format for assessing the care needs of prospective residents. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 10 The inspection carried out September 2007 found this continues to be the case. The manager continues to visit prospective residents to assess their care needs. The information collected is used as part of the resident’s plan of care. Residents are encouraged to visit the home before admission and the provider stated in their annual quality assurance assessment that they wish to improve this process by encouraging prospective residents and their families to share a meal during the introductory visit. One resident spoken with advised she was unable to visit the home, but her daughter visited and was provided with information about the services available. Brooke House DS0000049956.V350685.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 People who use the service experience adequate quality outcomes in this area. Residents’ health and well-being would benefit from recording of detailed information and staff developed a person focussed way of looking at care needs. Some areas of medication management need to improve to ensure residents health and welfare is not compromised and staff need to develop greater awareness of peoples dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care records: The previous inspection carried out July 06 found care records contained full assessments, comprehensive care plan guidance and accounts of residents’ health and care needs and risk assessments. Care records for people with dementia contained a recently introduced social profile with information about the person’s life history and significant events. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 12 The manager had implemented a more proactive approach to help safeguard residents from the risk of developing pressure areas. The inspection carried out in September 07 found care records contained information about some of the care needs of residents but the detail recorded was brief. The majority of the care records for people with dementia contained detailed accounts of their life history and wishes regarding their personal care needs, however, not all files contained this information. Parts of the care records are computer generated but this system does not always encourage staff to look at residents care needs from their perspective. The guidance in the records for how staff should address residents care needs is quite brief and does not always reflect on other information gathered, such as life stories. For example, the life history information for one resident indicate a love of music, but this had not been reflected in the actual plan of care and the record states “not capable of activities.” This shows a lack of understanding by care staff of the importance of providing stimulation and meaningful occupation for people with dementia in a person focussed way. Care records were also very focussed on residents physical care needs, but little information was recorded about how residents would like their emotional and social care needs met. Care planning for people who have dementia needs to focus on the person as an individual and particularly focus on peoples emotional and psychological care needs. Care records need to provide staff with a good understanding about what matters to the person with dementia and should show how they like to live their lives and want to be supported. Care records need to show the person as an individual with needs specific to them and currently these records are not totally doing that. Most of the daily records were brief and didn’t offer much useful information about how residents care needs were being addressed or how they were spending their days. Some care records for residents with significant care needs indicated they were at risk of falling and developing pressure sores but the guidance for how staff should manage these needs was too brief. For example, one resident has a pressure sore but the care record had not been updated to include that information and just indicated the person was at risk of developing sores. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 13 Staff spoken with discussed residents care needs and care records. Staff said the care records were useful, but felt they should contain more detailed information about residents care needs. They said the care was being given, but it was not always being written down in sufficient detail. Care records contained information regarding visits made by healthcare professionals showing residents healthcare needs are being monitored by staff. Medication: The previous inspection found residents medication managed and administered appropriately. The inspection carried out in September 07 found this generally continues to be the case but some anomalies were noted. Medication administration records (MAR) were being completed and an audit showed medicines given as prescribed, except for those receiving variable doses of medication. For example one MAR indicated a variable dose could be given for a painkiller, but staff were not always indicating how many tablets had been given. It was not possible to audit those medicines to see if they had been given as prescribed. The manager advised she was aware of this as she regularly audits medication. Some residents are prescribed medicines to have as required and some of these medicines were very strong painkillers and medicines (antipsychotics) given for behaviour that challenges. For staff to justify reasons for giving these medicines, care records should indicate when the resident should receive these medicines and currently they do not. Privacy and dignity: Residents said at the previous inspection they found staff to be helpful, respectful and courteous. The September 07 inspection found staff making every effort to care for residents, and residents spoke of how kind and caring staff are. Observations carried out in the Brookfields unit for people with dementia found staff hoisting residents in the lounge in full view of others. This indicates staff are not always aware of how they could respect peoples dignity. Brooke House DS0000049956.V350685.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 People who use the service experience good quality outcomes in this area. Although some residents lack sufficient engagement and occupation, others do benefit from staff supporting them with different kinds of occupation. Residents in Brookfields would benefit from an improved dining area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Daily life: The previous inspection found residents enjoyed plenty of contact with their relatives but were not satisfied regarding the provision of activities. Activities were provided, but residents were not always aware of them and the residents in Brookfields enjoyed activities arranged by the deputy manager. The September 07 inspection found residents able to carry on with their daily lives as they wish to. The majority of residents in the main house kept to their rooms and rarely used the communal areas or garden. A few residents were enjoying sitting in the garden and two were happy to walk around the home, but staff were not seen to engage with the residents or provide them with any activity or occupation except for the provision of a newspaper. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 15 One resident was sat in the lounge all day but received only minimal engagement and interaction from care staff. Staff on the Brookfields unit spoke of how residents there help with household chores such as laying tables, tidying the dining room and sorting items of laundry. This is seen as good practice as people with dementia often need to be occupied with activity such as this to help them retain a sense of identity and to feel valued as a person. Planned activities also take place and the deputy manager often brings in her dog which residents enjoy. Care records omitted information about how residents like to spend their days and failed to show how staff have been supporting people to maintain their hobbies and interests. Food: The previous inspection found meals were well presented and appeared of good quality. Some residents spoken with said they would welcome more variety in the menu. The inspection carried out in September 07 found food continues to be of good quality and residents enjoy a variety of meals. Residents confirmed the food was good and they had enjoyed spaghetti bolognese for lunch. Staff need to improve the way they assist residents with their meals as they were observed to feed residents by standing over them. They also didn’t converse with residents during the time they were assisting them and one staff was observed to give a resident their pudding in less than a minute. The dining room in the main house was beautifully laid out with well-presented tables offering residents a very pleasant dining experience. This room also opens out onto a lovely patio area accessible to residents who sometimes like to take their lunch out there. In contrast, the dining room in Brookfields is small and unable to accommodate all 14 residents. Tables were laid with cutlery and napkins but no tablecloths and appeared very different from the main house. This room has a door to the garden, but the part of the garden it opens out to is unsecured and therefore it remains locked. It is a shame that the residents here are not able to experience such a pleasant dining area as those who live in the main house and are unable to access the beautiful grounds because of the lack of secure outdoor space. Brooke House DS0000049956.V350685.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 People who use the service experience good quality outcomes in this area. Residents’ benefit from having concerns and complaints dealt with in a professional manner. The manager makes every effort to ensure residents are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous inspection found residents and relatives unsure of how to raise concerns. This has improved and the September 07 inspection found copies of the homes complaints procedure in residents’ bedrooms and communal areas. Comments received from relatives in a recent CSCI survey indicate they know how to complain. One resident spoken with had no complaints and was very happy, but would speak with staff if there were any concerns. However, one resident commented in the CSCI survey that “I know how to complain but they are often too busy and you cannot find them”. Staff spoken with said they would refer any concerns to the manager and were sure she would address them. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 17 Two complaints were received about care practices within the home earlier in the year. Both were referred to the provider for investigation. Both were thoroughly investigated and neither could be upheld. The manager advised staff would soon be undertaking training in safeguarding residents from abuse. Brooke House DS0000049956.V350685.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): 19,20,26 People who use the service experience adequate quality outcomes in this area. Although the main house is well maintained and well laid out, the health and well-being of residents’ in Brookfields is compromised because the surroundings and layout of the unit are not entirely suitable, enabling or supportive for their specific care needs. The layout and design of the garden also needs to be developed to meet the needs and improve the well-being of people with dementia. This judgement has been made using available evidence including a visit to this service. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 19 EVIDENCE: The previous inspection found the home was safe, clean and generally well maintained but a plan of long-term maintenance needed to be out in place. In addition, the garden and dining space for residents in Brookfields was noted to be inadequate. The September 07 inspection found many areas within the main house had been redecorated and the home continued to be safe and well-maintained. The home offers people who live in the main house access to a large and beautifully kept garden. The house itself offers many lovely period features making it an extremely pleasant place to live. Residents spoke of how lovely the home is and how much they appreciated being able to use the garden. Differences were seen in Brookfields however, and although this was a purpose built unit for people with dementia, it fails to offer residents with an enabling environment. The garden area is extremely small, and although efforts have been made to develop it into a pleasant area, it is still very small considering the huge garden areas beyond. Many bedrooms in this unit also have doors overlooking the large gardens, but because these gardens are not secure, residents are not permitted to use them. The manager and deputy have made some effort to improve the décor and corridors and bathrooms appear much less clinical and more pleasant. Further improvements are needed to help residents find their bedrooms, toilets and communal areas. The physical environment is very important for people with dementia and it must offer plenty of visual cues and way-finding guidance. The provider must consider how to make this unit a more enabling, suitable and supportive environment for the residents. The home was noted to be very clean and pleasant smelling throughout. Brooke House DS0000049956.V350685.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): People who use the service experience adequate quality outcomes in this area. Residents well-being is compromised because staff lack understanding and confidence regarding good dementia care practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous inspection found sufficient numbers of care staff were provided, but there were some difficulties with communication as the majority of staff were from overseas. At that time, 41 of care staff were qualified to NVQ 2 or above. The September 07 inspection found sufficient numbers of care staff and less staff had been recruited from overseas. The manager has made improvements to the duty roster and recruitment to ensure a mix of staff are on duty throughout the day. Residents spoke about how kind and caring the staff are but that they do have difficulty getting some of them to understand their needs. Comments received from relatives in a recent CSCI survey indicate staff provide a very kind and caring environment in the dementia unit, they said that usually the care is good and staff are kind but sometimes struggle to care for my relative who has severe dementia. A number of relatives commented that there are difficulties with the language barrier from a large number of overseas staff employed, but that they are kind to the residents. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 21 Staff spoke of how their colleagues from overseas are provided with English lessons and that they are very kind and caring with the residents. Observations of care staff interaction with residents showed they lacked confidence in their approach to people with dementia and were unsure about how to value those residents as individuals. Some staff have undergone training in caring for people with dementia, but some have not. Staff spoken with confirmed their training and said how useful the dementia care training had been. Information from the provider indicates 9 out of 28 care staff have achieved NVQ 2 or above and 3 are working towards it. One staff spoken with confirmed she was undertaking NVQ 3. New staff undertake induction training overseen by the deputy or the manager. It was not clear from staff records whether the provider has implemented the dementia care knowledge induction sets from Skills for Care. Files of newly appointed staff indicate the manager follows safe recruitment practices. Brooke House DS0000049956.V350685.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): 31,33,35,38 People who use the service experience good quality outcomes in this area. Residents’ benefit from living in a home that is managed by a competent person and from being included in how the home is run. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous inspection found the newly appointed manager exhibited a clear commitment to the role and had already completed a substantial part of her NVQ Level 4. Residents’ personal finances were not managed by the home and health and safety practices were adequate. The September 07 inspection found the manager had completed her NVQ 4, and a 4-day course in caring for people with dementia. The manager became registered with the Commission in September 2006. Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 23 No changes have been made to the way residents finances are managed. Quality monitoring continues to be carried out and a comprehensive and constructive report is compiled from a yearly formal survey with the findings clearly detailed. This report is made available to residents and relatives. So they can see how the manager has acted upon their comments and suggestions. Health and safety records showed the home managed in a safe way with the exception of the use of bed rails for residents. Risk assessments for the use of these rails need to be more robust and thorough to show they are not being used inappropriately. On occasions bed rails in other care services have been found to be dangerous causing harm to residents. Risk assessments in residents’ care files were not detailed enough to show the risk of using the bedrails had been thoroughly explored and alternative measures had been sought. Use of assistive technology in the form of floor mats linked to the call system was noted to be in use for some residents. As already mentioned in the report, the manager needs to make improvements in the following areas to ensure the home is being run in the best interests of the residents health, care and well-being: The development of a person focussed care culture to include a person focussed approach to care planning Care planning for people with significant care needs The development of staff knowledge and practice regarding caring for people with dementia. A more suitable and enabling care environment in Brookfields. Recruitment practices regarding obtaining suitable references. Brooke House DS0000049956.V350685.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 2 2 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement People who use the service should have a care record that contains full details of their entire range of care needs. People who use the service should have their dignity maintained at all times. People who use the service should be provided with an environment that meets their care needs, in particular the physical layout and design of the Brookfield unit must be suitable and appropriate for their care needs. This must include access to suitable garden space. People who use the service should receive appropriate care and treatment from staff who are trained and competent to meet their specific care needs. People who use the service should not be placed at risk from harm because of inappropriate use of bedrails. Therefore full, thorough and robust risk assessments should be in place for any person who chooses to have bedrails. DS0000049956.V350685.R01.S.doc Timescale for action 31/12/07 2. 3. OP10 OP19 12 (4a) 23 (2, a, o) 31/12/07 31/03/08 4. OP30 18 (1, c, i) 31/12/07 5. OP38 13 (4) 31/12/07 Brooke House Version 5.2 Page 26 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 Brooke House DS0000049956.V350685.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Brooke House DS0000049956.V350685.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. 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