Inspection on 31/05/07 for Brookfield

This inspection was carried out on 31st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brookfield 12/06/08

Brookfield 24/08/06

Brookfield 30/05/06

Brookfield 02/03/06

Brookfield 18/08/05

Brookfield 29/03/05

Brookfield 28/09/04

Brookfield 08/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Brookfield 7-9 Hayes Road Clacton on Sea Essex CO15 1TX Lead Inspector Diane Roberts Unannounced Inspection 31st May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookfield DS0000017783.V344644.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. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookfield Address 7-9 Hayes Road Clacton on Sea Essex CO15 1TX 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) 01255 427993 F/P 01255 427993 Mr Jos Dorval Mrs Lystra Dorval Mrs Lystra Dorval Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 11 persons) 19th January 2007 Date of last inspection Brief Description of the Service: The residential service is primarily aimed at older people (over 65 years) who require personal care and assistance. The home is not registered to admit service users who are diagnosed with a dementia condition. The home has a passenger lift installed to reach the upper floor. Most of the accommodation is within single bedrooms, although one twin room remains in use. The home pre-existed at the time of National Minimum Standards coming into operation on 1st April 2002, therefore the level of toilet and bathing facilities existing at that time remain available. On this basis, these facilities comply with requirements of National Minimum Standards. There is one sitting room and one dining room. There is a small courtyard garden to the rear. The home has a statement of purpose and service users guide in place. The current fees are £374.50 a week and additional charges are made for toiletries, hairdressing, newspapers etc. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The registered manager was available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A full tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 1 resident and 3 staff were spoken to during the inspection. The CSCI sent feedback/comment sheets to the home for both residents and relatives for completion prior to the inspection. Two have been received from relatives and the comments taken into account. A random inspection was carried out on the 19th January 2007 in order to review progress made in relation to previous statutory requirements and in relation to the improvement plan submitted by the manager. Overall the inspection still found significant shortfalls and an unrealistic approach by the manager who was stating that items and systems etc. were in place, when on inspection they were not. It remains a concern that the Proprietor/Manager, Mrs Dorval manages the home in response to the inspection process rather than in a proactive way to ensure positive outcomes for residents. Mrs Dorval’s management abilities are also of concern. There are some aspects of this service have failed to improve over the last two CSCI inspections. Statutory requirements in relation to these remain, as the improvements shown are not sufficient to meet the regulations. These are highlighted in the agenda for action. Consideration will be given to taking legal action should these outcomes not improve. What the service does well: Residents and relatives are generally happy with the standards of care and services at the home. Staff training is provided and the staff team at the home is stable and no agency staff are used. Staff recruitment is good and the home has a thorough induction programme in place. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 7 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 Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 8 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is needed on the assessment process to ensure that the home can fully meet the needs of residents it admits. EVIDENCE: The home has a pre-admission assessment system in place and assessments from recent admissions were inspected. The home was in receipt of Care Management assessments provided by social services highlighting the specific and immediate needs and relevant information for each of these people. The home had also carried out their own admission assessments, which did not fully reflect the needs identified within the Care Management assessments and briefly identified physical ability and dependency needs in personal hygiene, mobility and continence. An assessment score relating to ‘the residential care forum’ and ‘ barthel score’ assessment tools were included in the new assessment process, but Mrs Dorval’s showed limited understanding of them Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 9 when questioned. It remained unclear as to how these scores were concluded or utilised within the overall assessment. The home continued to use the same standard letter to the prospective resident informing them that the home can meet their needs but did not say how they proposed to do this. Further work is needed to ensure that a satisfactory assessment process is in place to evidence that the home can fully meet the needs of prospective new residents. New residents were noted to have copies of the service users guide. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The basic care at the home is acceptable however a more detailed and individualised approach to care is needed to ensure that residents’ needs are fully met in a proactive way. EVIDENCE: Since the last inspection there has been no further progress in the development of care plans with regard to their content. Equally they have not deteriorated. They remained basic and brief in detail and were not developed according to the individuals’ Care Management assessment. Whist the care plans reflected some elements of individually tailored care, the space available on the form limited the amount and clarity of the information provided. The care and support plans continue to lack essential information relating to behavioural, emotional, social, mental and physical health needs. This was particularly evident in the case of the two new admissions with regard to cognitive impairment, confusion and short term memory loss. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 11 Risk assessments continue in a tick box format and do not clearly clarify the risks or hazards identified or provide instruction with regard to reducing the risks identified. Some are contradictions, for example, area of ‘personal care ability’ is ticked excellent or good but a comment states ‘requires assistance’. Clear management strategies of risk were not incorporated within care planning arrangements for example: continence assessments did not include preventative measures for risks such as pressure sores. A falls assessment stated ‘ to accompany them’; it did not include preventative measures such as how to maintain a safe environment, suitable footwear, etc. The care plan review records indicated this person was found ‘asleep on the floor’. The same person required support to meet nutritional needs. The dietary records recorded the food served but did not identify how much food was consumed, a comment at the end of the sheet for the week stated that this persons appetite had deteriorated that week. There was no evidence to demonstrate how this conclusion was reached or managed. Review records identified changing needs such as a sore bottom and faecal incontinence but renewed management strategies were not incorporated within a new plan of care. This is important to ensure staff are informed of the way in which new agreed action for care is to be delivered and outcomes to be achieved. Health records indicated prompt referral to healthcare professionals and information received but again No section of the care plan detailed any planned action or medical or healthcare advice received to enable staff to support the resident. One resident spoke about having back pain, care records indicated that the GP was called and medication was prescribed. This person’s care plan did not reflect physical health care needs associated with a diagnosis of chronic arthritis and the conservative support required of staff to promote comfort or reduce stiffening and pain. It was noted that this person’s chair was not suitably located to enable easy viewing of the television, her twisted positioning may potentially contribute to the back pain. It was noted that the medication records for this person recorded PRN (as and when required) analgesia medication at set times and the entry against 08.00 was blank. This did not give a clear indication that the medication was given appropriately or according to when it was required. The care plan did not clearly indicate that appropriate monitoring was in place with regard to how often analgesia was given/required or if the medication was effective. Relatives commented that communication was usually good from the home and that they felt the needs of their relatives were usually met. Suitable locked storage facilities were not provided for controlled drugs. A small lockable tin was kept inside the medication trolley; the tin was not big enough to hold the amount of prescribed opioid analgesia prescribed to some residents, this was therefore stored in the same way as other prescribed Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 12 medication. This was raised at the last inspection and shows a limited management approach. Since the inspection the manager has confirmed that a new cupboard has been provided. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A more individual approach is needed with regard to social care to ensure that residents have positive outcomes in this area. Food provision in the home still requires work to ensure that a quality service is offered. EVIDENCE: On arrival five residents were observed in the lounge dozing. Music was playing and was appropriate to the resident group. A daily activity timetable was observed in the staff area which was more task orientated than an individually tailored approach to suitable and appropriate occupation according to peoples choice and preference as and when they required. Monday – Music, sing along and dance Tuesday– cake baking with support Wednesday– cream tea, cake making, sherry morning, shopping for cakes. Thursday – cards, dominoes, puzzles, papers and magazines Friday– shopping/sea front, dance and exercise Saturday– films, videos and cake making Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 14 Sunday – sherry morning, socialise and chat At the bottom of the timetable it states ‘ residents can go out at ay time’. From observation and staff rota, staffing levels are limited to two, most days, it is therefore unclear as to how residents are supported to go out at any time, particularly as staff also carry out cooking duties. Care plans did not indicate that residents had participated in any of these activities nor the outcome or benefit anticipated for the resident. One resident spoken to did confirm that they had been out to the shops and to a café recently and had a choice about how they spent their time during the day. The Care Management assessment for each of the new residents stated they each required support in maintaining social stimulation and emotional support. One new resident described an active life previous to her illness and admission and enjoyed socialising and going out. The home had not explored with this person how they could support her and the care plan simply stated that she likes to go to town three times a week. Records indicated that this person had gone out on two occasions. Consideration needs to be given to how service users can receive a service tailored to their individual and diverse needs and promote optimal independence. The service generally needs to develop its competence in meeting the needs of residents with varying levels of cognitive impairment. Menus and food stocks were reviewed and it was found that there still was a significantly high use of convenience/processed and value brand foods. The use of such food products and their high salt and sugar content was discussed with the management at the previous Key inspection and a good practice recommendation was made for the home to seek advice and guidance from a dietician or nutritionist. A dietician had assessed the menus but not residents’ individual nutritional needs. Whilst the dietician said that the menus were well balanced and suitable for the residents group, she suggested that more variety would be good across the menu and to not to use cheap brand foods for elderly people due to the nutritional content. Value brands were still noted in the home. The menus and food stocks were similar to the last three inspections. There was no evidence of fresh fruit or vegetables or fruit juice. The menu continues to state that fruit juices are available for breakfast; the manager stated that fruit squash was preferable with the residents. It was noted that frozen vegetables were boiling at 11.20am and were not required until 12.30pm; frozen vegetables would generally only require a few minutes to cook and prolonged boiling would not only destroy the nutritional value but the flavour and consistency of the vegetables. There remains a concern that residents could be receiving a more nutritionally sound menu, with more variety. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems in place are acceptable but work needs to be done in order to ensure that the complaints procedure is accessible to everyone. EVIDENCE: Since the last inspection, the complaints procedure has been reviewed and updated. It is now displayed where more people can access it along with blank complaints forms in a holder. This is an improvement. There have been no complaints since the last inspection and it is therefore not possible to assess how effective the manager is at addressing any concerns. One resident spoken to said that they would be comfortable to raise any concerns and had the complaints procedure in a copy of the service users guide. All of the relatives who commented stated that they did not know how to make a complaint to the home and the manager should address this as she states, in her annual quality assurance assessment, that all relatives are aware of the procedure. The home now has an acceptable adult protection policy in place with the associated local guidance. Staff were able to demonstrate an understanding of adult protection procedures. Staff appraisals show that the staff and the manager have identified adult protection as a training update needed this year, with the last training being provided in 2005. The manager confirms in the annual quality assurance assessment that this training is planned. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standards of the premises are acceptable but would benefit from an ongoing proactive approach by the manager in order to improve outcomes for residents. EVIDENCE: A full tour of the premises was undertaken. At this inspection the nurse call system was working throughout the home. Outstanding work on the electrical systems from September 2006 had also been completed. It was positive to note that some bedrooms had been decorated and tidied since the last inspection. This gives a better impression of the home and makes the environment more pleasant for residents. The downstairs hallway has been recarpeted since the last inspection and the manager plans to replace some Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 17 carpets in some of the bedrooms, where they are poor. The floor in one bedroom, noted at the last inspection, has been repaired. The manager has been consulting with the local fire authority with regard to access of fire exits and alterations to one bedroom involving installation of an ensuite, making the bedroom a single. This has yet to be confirmed with the CSCI. Some new chairs have recently been purchased for the home and the flooring has been replaced in some ensuite, which has addressed previous odour problems. Since the last inspection, window restrictors have been fitted to upstairs windows. The home was seen to be clean and no odours were noted. Care staff currently undertake all cleaning tasks. Relatives commented that the home could improve by ‘providing brighter and fresher accommodation’. Fire safety was reviewed and the checking and maintenance systems were seen to be in place and up to date. The recent fire officer visit showed that some door closures needed attention and signage should be upgraded. The manager stated that she planned to attend to this and it was later confirmed to the CSCI that this work had been carried out. The home has a satisfactory fire risk assessment in place that was completed by an external contractor in March 2005 and reviewed by a staff member this year. It is recommended that this be reviewed more regularly. It was noted in one bedroom that a wall heater was showing signs of getting hot and scorching. This should be risk assessed and the appropriate safety action taken. This was highlighted to the manager. Other heaters in the home were not of concern. The laundry is located outside at the rear of the home. It is good to see that work is underway to improve this area and provide a more suitable environment for this work. The manager states in her annual quality assurance assessment that the staff do check the premises and record anything noted in the ‘occurrence book and repeat this to the manager’. The manager goes on to state that she needs to check the environment regularly and complete a risk assessment. A maintenance log is maintained but records are limited and do not evidence that the work has been done and when. Whilst some systems are in place a more proactive approach by the manager, to the ongoing maintenance of the premises would be of value. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing at the home is stable, with adequate training being provided but the manager needs to review the staffing levels to ensure that all the needs of the residents can be met. EVIDENCE: The home has a stable staffing team. Staffing levels are currently 2 care staff plus the manager am and part pm. 2 care staff late pm and one awake and one asleep at night. On discussion with the manager and the staff, they agree on the current dependency levels of the residents and feel that they can meet the needs of the current residents with these levels. The manager stated that she plans to employ a cook if the resident levels go up from 7, as at the current time the care staff do all the cooking and cleaning, which does take them away from residents’ physical and social care needs. The manager needs to keep staffing levels at the home under close review to ensure that residents’ needs are being fully met, especially in relation to social care, which is currently limited. No agency staff have been used in the past three months. The manager states in the annual quality assurance assessment data set that over 50 of the care staff have NVQ level 2 and above. One new member of staff has been employed since the last inspection. Recruitment procedures were checked and found to be generally in good order Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 19 with an experienced member of staff being recruited. No interview records are kept and it is recommended that this be addressed. It is also recommended that the application form be reviewed in light of age discrimination act and to give a longer career history. There was no evidence that the GSSC booklet had been issued to the new member of staff. This should be addressed. The home has a policy in place for staff supervision and this should be carried out bi-monthly. Records seen evidence that this is happening and records identify training needs. The manager does not have a training programme in place and uses the supervision/appraisal records and staff files to identify need. The home is now using the Skills for Care induction and evidence was available to show that the new member of staff was undertaking this. Induction records were reviewed and it is recommended that some of the areas require more detail in the answers to demonstrate the knowledge of the carer. Staff training records show that staff are up to date with mandatory training and have attended some additional training on dementia, falls prevention and health and safety. The manager needs to work on using the skills and knowledge gained by staff through training to improve services and facilities in the home so outcomes improve for residents. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager abilities are still of concern and she still needs to put systems in place that ensure that the home is maintained and services developed in a proactive way, with residents and relatives comments in mind so that outcomes for residents improve. EVIDENCE: The manager confirms that she has completed the registered managers award but has yet to receive the certificate. The inspecting officers are disappointed to note that despite undertaking this qualification the manager has yet to put proactive, consistent systems into place which reflect her learning on the course and that would benefit the residents and the home in general. Whilst Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 21 some steady improvements are being made it remains a concern to the CSCI of the overall management abilities of the current manager. It is felt that the development of the home is often linked to items raised at the time of inspection rather than a proactive management approach by Mrs Dorval. A basic quality assurance system is in place, which consists of short feedback questionnaires for residents, relatives and visiting professionals. There is not a systematic approach and no analysis of results. The questionnaires are limited and the results would be questionable as to how much they could help inform and improve practice and facilities in the home. No other audits are currently in place and this is an area for development work in the home. The manager does not refer to quality assurance systems in her annual quality assurance assessment and continues to show a limited understanding of quality assurance processes. The manager confirmed that at the current time the home does not hold any monies on behalf of residents. Items are purchased on behalf of the residents and then invoices are raised and sent to relatives. The manager says that in the future this system may change and they will keep appropriate records. A health and safety risk assessment for the premises was completed in done in September 2006. Records show that this was due for review in March 2007 but had not been done. The assessment was seen to be basic and not fully completed. There was also no evidence of follow up on any issues identified. The value of this assessment is questionable. The manager stated that ‘a tutor’ completed the assessment and dates are wrong. On further discussion with the manager, there are no systems in place for assessing health and safety in the home or a risk assessment system. This should be addressed. The manager states in her annual quality assurance assessment that ‘risk assessment on environment and maintenance are check and recorded’. Accident records were inspected and found to be satisfactory. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 22 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 2 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Each resident must have a detailed pre-admission assessment in place and be assured that their needs will be met by the home and how they will be met. The team must undertake further work to ensure that all residents’ health, personal and social care needs are set out in a detailed individual plan of care. This is a repeat requirement. Residents’ risk assessments must contain sufficient detail to fully identify the risk and outline management strategies. Residents’ lifestyle within the home must match their expectations, preferences, needs and aspirations in an individual way. This is a repeat requirement. Residents must receive a varied, wholesome, nutritious and balanced diet. The use of value food should be reduced and the advice of the dietician taken into account with regard to variation. This is a repeat requirement. DS0000017783.V344644.R01.S.doc Timescale for action 31/08/07 2. OP7 OP8 15 31/08/07 3. OP8 13 31/08/07 4. OP12 OP13 13, 15 31/08/07 5. OP15 16 31/07/07 Brookfield Version 5.2 Page 24 6 OP19 13 23 7. OP27 18 8. OP31 9 9. OP33 9,10, 24, 26 The manager needs to develop a system whereby the premises are regularly checked in relation to maintenance and health and safety. The numbers and skill mix of staff needs a formal review to ensure that residents’ needs are fully met, especially in relation to social needs. This is a repeat requirement. The home must be managed in a competent manner with the appropriate management systems in place and ongoing development of services and facilities. This is a repeat requirement. The home must have robust quality assurance systems in place to help ensure that it is run in the best interest of service users. This is a repeat requirement. 31/08/07 31/07/07 31/07/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Brookfield Refer to Standard OP10 OP14 OP16 OP19 OP29 Good Practice Recommendations Residents care plans should be person centred and detailed enough to ensure equality and diversity issues are covered. Care plans should demonstrate that residents’ choices regarding daily routine have been consulted on and acted upon. The manager should ensure that all relatives are aware of the complaints procedure. The manager should continue to upgrade the premises in relation to décor and carpets etc. Staff should be issued with the GSCC Code of Conduct and DS0000017783.V344644.R01.S.doc Version 5.2 Page 25 a review of the application form and provision of interview records should also be considered. Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Brookfield DS0000017783.V344644.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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