Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 15/08/06 for Brookfield Nursing Home

Also see our care home review for Brookfield Nursing Home for more information

This inspection was carried out on 15th August 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The management has recruited additional staff to reduce the amount of agency staff used. A training programme is now in place, which will promote a welltrained and competent staff. The recruitment policies and procedures are robust and all members of staff are supervised to help develop their knowledge and skills for the benefit of the residents.

What has improved since the last inspection?

An ongoing programme of redecoration and refurbishment promotes a safe and homely environment for the residents. Major improvements have been made by the replacement of the hot water boilers and hot water is now available throughout the upper floor. Pureed diets are now prepared appropriately for the benefit of residents who require this.

What the care home could do better:

There is an urgent need to revise the care planning process and documentation, which is significantly below the standard required. The registered person needs to ensure that all events that adversely affect the safety and welfare of residents are notified to the CSCI and that requirements are met within the given timescales.

CARE HOMES FOR OLDER PEOPLE Brookfield Nursing Home Grange Road West Kirby Wirral CH48 4EQ Lead Inspector Les Smith Unannounced Inspection 15th August 2006 08:30 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 Nursing Home DS0000020903.V297898.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 Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookfield Nursing Home Address Grange Road West Kirby Wirral CH48 4EQ 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) 0151 625 5036 0151 625 2037 Brookfield Nursing Home (West Kirby) Limited Mrs Alison Bebu Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty Four (24) Older Persons (aged over 65) and one (1) named male person (aged under 65 years) within a total of 25 28th January 2006 Date of last inspection Brief Description of the Service: Brookfield is a medium sized care home providing care for older people requiring nursing care. It is located in a quiet residential area of West Kirby on the Wirral. Local amenities such as shops, library, cafes, restaurants, churches and pubs can be found nearby. The care home is also situated near to the local beach and Dee estuary. Accommodation is provided over two floors with all rooms offering single occupancy. There is a small enclosed, private garden to the rear of the home and a car park to the front. Wheelchair access is provided to the home and a lift to the first floor. Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over a period of eight hours in the presence of the registered manager. During the visit time was spent examining records, policies and procedures and a tour of the home was undertaken. Discussions took place with residents, relatives, and members of staff, the registered manager and the organisations general manager. The home has improved overall since the last visit but it is a concern that requirements made previously are still outstanding. The home is reminded that it is a requirement to inform the Commission of any event that could effect the health, safety and welfare of residents. Residents spoken to were all complimentary about the home and the staff. Comments ranged from ‘I have nothing to complain about’ to ‘the staff are very good and do everything they can’ and ‘the food is very good and always on time’. Questionnaires were sent to 10 relatives and 4 GPs’ to elicit their views on the service provided by the home. Responses to questionnaires sent to a random selection of relatives / representatives of residents Yes 1 2 3 4 5 6 7 8 9 10 Do staff welcome you in the home at any time Can you visit your relative/friend in private Are you kept informed of important matters affecting your relative/friend Make decisions, are you consulted about their care In your opinion are there always sufficient members of staff on duty Are you aware of the homes complaints procedure Have you ever had to make a complaint Are you made aware of forthcoming inspections Do you have access to a copy of the inspection reports on the home Are you satisfied with the overall care provided 4 4 4 4 3 1 0 0 1 4 No 0 0 0 0 1 3 4 4 3 0 Comments Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 6 Responses to questionnaires sent to a random selection of General Practitioners with patients residing at the home Yes 3 3 2 3 2 3 3 1 1 3 No 0 0 0 0 0 0 0 2 0 0 1 x don’t know 1 x never asked for 1 comment of usually Comment 1 2 3 4 5 6 7 8 9 10 Does the home communicate clearly and work in partnership with you Is there always a senior member of staff to confer with Are you able to see your patients in private Do staff demonstrate a clear understanding of the care needs of service users If you give any specialist advice is this incorporated into the service users plan Is service users medication appropriately managed in the home Do management/staff take appropriate decisions when they can no longer manage the care needs of the service user Have you received any complaints about the home Is the inspection report made available to you on request Are you satisfied with the overall care provided to service users within the home 1 response of don’t know What the service does well: 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. Brookfield Nursing Home DS0000020903.V297898.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 Nursing Home DS0000020903.V297898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents or their representatives have sufficient information to allow them to make an informed decision about accepting a place but cannot be assured that the home is able to meet their needs. EVIDENCE: The home has revised and produced a combined Statement of Purpose and Service User Guide. The document is well-presented, easy to read and contains all the required elements. All residents or their representatives have been provided with a copy of the revised document. A selection of files was examined and all contained an appropriate contract or Statement of Terms and Conditions. Pre-admission assessments were seen in the care files examined. The assessments seen were inadequate in that they did not provide sufficient information for an initial care plan to be constructed. The revised preadmission documentation does not allow for the level of information required Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 9 based as it is on a series of yes or no questions with no provision for expansion e.g. Is a hoist required – if the answer is yes there is no provision for hoist type, sling size etc. There is a need to ensure that sufficiently detailed information is obtained in order to assure the prospective resident or their representative that the home has the capacity to meet their identified needs. The Pre-admission assessment should as far as practicable involve the family and all other health care professionals and evidence of that involvement provided in the assessment. The home has all the appropriate equipment and facilities to meet residents’ needs. Equipment and aids provided by the home include assisted baths, adaptions such as raised toilet seats and grab rails, hoists and slings and slide sheets for transferring and moving residents comfortably and safely. Wheelchair access is available to all areas of the home including the garden areas. Visitors and prospective residents are encouraged to visit the home at any time and as often and for as long as they as they wish when deciding whether to request or accept a place at the home. The home also offers trial stays with a view to permanent residency subject to availability. Brookfield Nursing Home DS0000020903.V297898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of comprehensive and consistent care planning, risk assessment and review places residents at risk of harm or injury. EVIDENCE: Care plans are in place for all residents based upon a care needs assessment on admission to the home. The care plans whilst appearing comprehensive are not consistent in format and lack distinct risk assessments. The care documentation is confusing as needs; goals, interventions and assessment of risks are merged together. All care plans include interventions that may or may not be required by that individual resident. There is lack of detail within the plan e.g. ‘mobile with carer’ does not specify whether one or two carers are required and such discrepancies places the resident at risk. Risk assessments are very general and do not provide clarity in relation to specific activities e.g. transferring from chair to bed or chair-to-chair. The care plan and associated risk assessments must be clear individualised discrete documents each with clear and unambiguous functions to allow for risks to be clearly identified and managed affectively. Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 11 Care plan reviews had been carried out on a regular monthly basis and did detail changes to care but the changes were not reflected in the interventions required. There is an urgent need to review the documentation in relation to care planning to promote clarity and individualisation of care. Examination of wound management records showed that information was not always present in the detail required. Full mapping of wounds or sores must be undertaken to ensure that improvements and deteriorations can be identified in the early stages to further plan the treatment to be given. Daily report sheets were generally completed in a good amount of detail. The statements made gave a good indication as to the actual care delivered, the outcome of that care and how the resident has spent their day. Residents identified as having cognitive or sensory impairment had no plans in place to address their special needs and plans in relation to their activities of daily living failed to reflect the additional input and care required. Records examined showed that health care needs were met with referrals to tissue viability specialist nurses and other health care professionals such as dieticians. All residents are registered with a GP and records showed that requests for visits are made. The standard of medication management has fallen since the previous visit. Medication was not always signed for on administration. Failure to record the administration of medication places residents at risk of harm, as nurses are unable to tell when the last dose of medication was administered. Handwritten transcriptions were seen that lacked a clear dosage. One MAR was seen with a handwritten script for Co-Codamol but there was no indication as to whether this was for C0-Codamol 8/500 or Co-Codamol 30/500. Other handwritten transcriptions were seen that had no signatures or dates and frequency was recorded by use of abbreviations. The use of abbreviations such as ‘TDS’ and ‘QID’ on MAR sheets is not best practice and should be stopped. One resident had been prescribed Pro-Cal, which had then been discontinued. The Pro-Cal was given for a further two days after it had been discontinued. The MAR sheets show that all morning medications are scheduled for 0700. This is before breakfast and is not acceptable unless specifically required. The manager confirmed that morning medications are in fact given with or after breakfast i.e. between 0830 and 1000. The MAR sheets should reflect the time the medications are given. The temperature of the drug fridge was recorded on most days but gaps were evident. The temperature of the clinical room is recorded but again gaps in the recordings were evident and the recordings made showed that the temperature was consistently being recorded in excess of 250C. Stored medications should not be kept at temperatures in excess of 250C in accordance with manufacturers recommendations. When drugs are prescribed on a ‘take one or Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 12 two as required’ the number given must be recorded. The manager explained that she usually monitors the medication records but that she had been on holiday and that this was her first day back on duty. The home is reminded that all trained nursing staff are accountable for their own practice and that compliance with the Nursing and Midwifery Councils Code of Professional Practice is a requirement for all trained staff. All residents are accommodated in single rooms and it was observed that care was taken by staff to ensure that residents’ privacy and dignity was respected at all times. All personal care was carried out in personal rooms or the bathroom. Policies and Procedures are in place assure residents and their families that they will be treated with care, sensitivity and respect at the time of their death. There is a need to expand the policies and procedures to take account of different cultures and spiritual requirements. Care files showed that residents or their representatives had been consulted in relation to their personal wishes. Brookfield Nursing Home DS0000020903.V297898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. As far as practicable residents have choice and flexibility in how they spend their day at the home and a limited range of social and recreational activities are available to promote individual independence and wellbeing. EVIDENCE: Residents’ are supported by staff to exercise their choice in many aspects of their life and are encouraged to make decisions such as the time they wish to go to bed or get up. The home has 3 part-time activity co-ordinators who provide a total of 20 hours per week. Activities range from bingo, shopping trips, special themed teas and religious services supplemented by external entertainers. The programme for activities is very general and gives no details of specific activities for residents to choose from. There is a need to record participation in activities within the care files in order to establish the preferences of individual residents. This would enable the likes and dislikes of individual residents in line with their personal interests to be established. There is also a need to provide more social and recreational on a one to one basis for those residents who for whatever reason do not participate in-group activities. Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 14 The local ministers of various faiths provide spiritual care. An ecumenical service is held at the home every other week and the various ministers visit regularly. Visitors are welcome at the home at any time and this was observed during the day of this visit. Residents take breakfast as and when they rise and a cooked breakfast is always available if required. Residents have the choice of taking their meals in their own room, the lounge or the dining room as they wish. Brookfield Nursing Home DS0000020903.V297898.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents or their representatives can be confident that any complaints will be taken seriously and that systems are in place to protect residents from abuse. EVIDENCE: There have been no complaints since the last inspection either to the home or directly to the CSCI. One care file examined gave detail of a verbal complaint made and the discussion that took place between the relative concerned and the manager. It is strongly recommended that informal verbal complaints also be recorded in the complaints register together with details of actions taken to promote an open and transparent approach to complaint management. All residents are registered on the electoral roll and assistance is provided as required to enable residents to exercise their rights. The home has policies and procedures in place in relation to Protection of the vulnerable Adult including Whistle Blowing and the ‘No Secrets’ document. Staff training records showed that staff had received training in adult abuse, its various forms, recognition and procedures to follow. This was confirmed by conversations with members of the staff who were able to demonstrate awareness of adult abuse and appropriate procedures. Brookfield Nursing Home DS0000020903.V297898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment at Brookfield has improved and the continuing programme of decoration and refurbishment promotes a safe, homely and comfortable place to live. EVIDENCE: The hot water boilers have recently been replaced and the outstanding problem with hot water on the upper floor has been resolved. The sluice rooms have been completely refurbished. The backlog of maintenance that was evident on the last visit has been addressed as evidenced by the lack of minor problems. The fire door to the back stairs does not close properly and this was a requirement at the last visit and must be addressed as a priority. The windows at the rear of the home remain in poor condition and the manager said that these were being replaced during the coming weeks. It is a serious concern that the emergency lighting at the home had been out of use for three weeks at the time of this visit. This had not been reported to Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 17 the CSCI, as required and appropriate contingency plans had not been put in place. Replacement lighting and staffing modifications were put in place with immediate effect. There are sufficient and suitable toilets and washing facilities, which include walk-in showers and assisted bathrooms. The home has appropriate and relevant aids in place throughout the home to help maximise independence. Hand rails, a nurse call system, raised toilet seats and pressure relieving aids were all seen and a lift to all floors gives access to all areas of the home. Residents are positively encouraged to bring their own possessions and memorabilia into the home and personalisation of rooms was seen throughout the home. On the day of inspection the home appeared clean and hygienic and was free from any odours. Staff members have received training in infection control and were observed working in accordance with the homes policies. Brookfield Nursing Home DS0000020903.V297898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members are recruited via robust policies and procedures, are well trained and deployed in sufficient numbers and skill mix to support and protect the residents. EVIDENCE: Examination of the off duty rosters showed that there were sufficient staff on duty at all times to meet the assessed care needs of the residents with one trained and five care staff on duty in the morning, one plus three in the afternoon and one plus two at night. The registered manager has an allocation of six hours for administrative duties and it is strongly recommended that this be reviewed. The home has attained the minimum level of NVQ trained staff with 60 holding NVQ level 2 or above and a further four staff are currently working towards the qualification. In addition to mandatory training the home is providing specialist training in Parkinson’s disease, Elder abuse, nutrition and care of the dying. A selection of staff personnel files including most recent starters was examined. All required items with relevant certificates were seen to be present including two references, copies of Terms and Conditions, PovaFirst clearances and Criminal Record Checks. Appropriate verification of ‘PIN’ numbers for trained members of staff were also seen. Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 19 The staff personnel files are located in the organisations head office, which is in the same building. However, access to the files and other records is restricted as the office is only open on weekdays. The record keeping system needs review to ensure that all appropriate and relevant records are accessible at all times for inspection as required. All new staff members undertake a ‘Skills for Care’ compliant induction using a commercially produced induction to care programme. There has been progress in ensuring that all staff members receive appropriate training. A training programme is in place and ongoing with courses scheduled for continence, manual handling, food handling, and fire safety, Elder abuse, First aid, bereavement and stroke awareness. Brookfield Nursing Home DS0000020903.V297898.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management at Brookfield requires strengthening to promote the health, safety and welfare of residents. EVIDENCE: The registered manager is a first level nurse with substantial experience of care of the elderly is registered with the CSCI and will be completing her NVQ level 4 in the near future. The home monitors its own quality assurance programme and regularly surveys the residents and their representatives in relation to the service provided. The last survey carried out was in January 2006 and relevant changes were made based on the findings at that time. The senior management have considered the feasibility of obtained an external quality Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 21 award and are planning to undertake and obtain ISO9000 with the British Standards Institute. Staff meetings are held regularly every three months. The ongoing self-monitoring is not as effective as it should be. The lack of response to findings e.g. the fire door not closing, potentially places the residents and staff at risk. Records were seen to demonstrate that staff supervision is in place and carried out at appropriate intervals. Certificates were seen for the periodic electrical safety, PAT tests, fire extinguishers and fire alarms. The gas certificate seen expired on 27 July 2005. A service contract was seen for the lift but no 6 monthly Loler certificates were available. Brookfield Nursing Home DS0000020903.V297898.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 3 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 2 Brookfield Nursing Home DS0000020903.V297898.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(1) Requirement The registered person must ensure that new service users are admitted only on the basis of a full assessment undertaken by people trained to do so and to which the prospective service user or their representative and any relevant professionals have been party. The registered person shall ensure that the care home is conducted so as: (a) to promote and make proper provision for the health and welfare of service users to make proper provision for the care and, where appropriate, treatment, education and supervision of service users 30/09/06 Timescale for action 30/09/06 2 OP4 12 & 18 30/09/06 (b) 3 OP7 14(2) The registered person shall ensure that the assessment of the service user’s needs is (i) kept under review; and (ii) revised at any time when it is necessary to do so DS0000020903.V297898.R01.S.doc Brookfield Nursing Home Version 5.2 Page 24 4 OP7 15(1) 5 OP9 13(2) 6 OP12 16(2)(n) having regard to any change of circumstances. The registered person shall, after 30/09/06 consultation with the service user, or a representative of his and relevant health care professionals prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The registered person must 30/09/06 ensure that medication policies and procedures be reviewed in line with Royal Pharmaceutical Society of Great Britain and Nursing & Midwifery Council guidelines to cover all aspects of medicines management. 30/09/06 The registered person shall having regard to the size of the home and the number and needs of service users consult service users about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of service users, activities in relation to recreation, fitness and training. The registered person is required to ensure that the home is reasonably maintained both internally and externally and notify the CSCI when outstanding work is completed – refer to external window frames (Previous requirement for 28/02/06 not met) The registered person must ensure that adequate arrangements are made for containing of fires (Refer to faulty fire doors) Previous requirement for 28/02/06 not met 30/09/06 7 OP19 23 8 OP19 23(4)(c) (1) 30/09/06 Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 25 9 OP37 17 10 OP38 37(1)(e) 11 OP38 13(4)(a)(c) The registered person must 30/09/06 ensure that all relevant records are (a) are kept up to date; and (b) are at all times available for inspection in the care home by any person authorised by the CSCI to enter and inspect the home The registered person must 30/09/06 ensure that any event, which adversely affects the wellbeing or safety of any resident, is notified to the CSCI. Previous requirement for 28/02/06 not met The registered person must 30/09/06 arrange for all safety checks to be carried out and forward copies of relevant certificates to the CSCI (Refer to gas safety certificate and Loler certificates for lift) Previous requirement for 28/02/06 not met 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 Refer to Standard OP16 OP27 Good Practice Recommendations It is strongly recommended that a record is kept of all complaints including verbal complaints which includes details of any investigation and any actions taken It is strongly recommended that the number of supernumerary hours allocated to the manager for management functions be reviewed. Brookfield Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 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 Nursing Home DS0000020903.V297898.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!