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Inspection on 25/03/08 for Brookfield Residential Care Home Limited

Also see our care home review for Brookfield Residential Care Home Limited for more information

This inspection was carried out on 25th March 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

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

Brookfield is a large home in a quite residential area of Prestwich and provides spacious accommodations for people living there. Since our last visit some new people have moved into the home and some long-term members of staff have left however people have remained stable and continue to be supported by regular members of the team. The team have good working relationships with health care professionals who regularly visit the home offering additional support and advice when needed. A feedback survey was received from a consultant psychiatrist who visits the home. Their comments included; `it is a suitable care home for people with long term needs who are unlikely to move to independent living`, `staff always up to date`, `calm and predictable environment`, good supervision of medication and mental health needs`, `support people in meeting health care needs` and `good assistance and management of people who present with a risk of aggression`.Feedback was also received from 4 staff members, which were positive about the support provided, communication between the team and that they were able to carry out their role properly. One person also commented, `we maintain a good, lively environment and the home is very clean.

What has improved since the last inspection?

A number of requirements and good practice recommendations made at our last visit have yet to be addressed. These must be addressed. Opportunities for staff training have been provided. These have included food hygiene, fire safety and adult protection.

What the care home could do better:

A letter has been sent to the provider with regards to work needed to the outside of the home and information about monitoring visits. These issues have been outstanding for some time. The provider has been requested to respond by the 4 April 2008 stating what action has been planned or taken. Information recorded in the care plans needs to be expanded upon to include all relevant support needs including areas of potential risk and how they are to be minimised. The manager is asked to provide a copy of the annual training plan for the forthcoming year showing what training opportunities are to be provided for staff around meeting the specific needs of people living at the home. A more robust system of gathering information when recruiting new staff needs to be put in place ensuring that all relevant checks and information are received prior to people commencing their employment. This will ensure that people living at the home are not placed at risk. Consideration needs to be given with regards to the management of staff hours ensuring some members of the team do not work an excessive number of hours. The manager is asked to provide us with a copy of the homes refurbishment and redecoration plan for the forthcoming year. The manager is to undertake a quality audit including sending out feedback questionnaires to people involved with the service. Once all information is received this is to be developed into an annual report. A copy of this should be sent to us.

CARE HOME ADULTS 18-65 Brookfield Residential Care Home Limited Brookfield St Anns Road Prestwich Manchester M25 9QE Lead Inspector Lucy Burgess Unannounced Inspection 25 March 2008 09:30 Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 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 Residential Care Home Limited DS0000008454.V349144.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 Adults 18-65. 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 Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookfield Residential Care Home Limited Address Brookfield St Anns Road Prestwich Manchester M25 9QE 0161 773 1165 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) Brookfield Residential Care Home Limited Mr Barry Douglas Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number 14, there can be up to 14 Adults with Mental Disorder (MD); 3 Adults with Mental Disorder over 65. The service should employ a suitable qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 7th November 2006 Date of last inspection Brief Description of the Service: Brookfield is a care home providing personal care and accommodation for 14 adults with a mental disorder. Three of the places are registered for people over the age of 65 years. The registered provider is Mrs Joan Rawlinson and Mr Barry Douglas manages the home. The fees range from £373.00 to £563.00 depending of the assessed needs of individuals. The home is situated in Prestwich, close to the shopping centre, local pubs and bus routes. Brookfield is an old Victorian house, which opened in 1991 and provides accommodation on 3 levels. It has 14 single bedrooms, a large lounge, dining room, kitchen and separate laundry. The home is set in its own grounds with a well-maintained garden and patio area to the rear of the property. There is a small car park area to the front of the building. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was a key inspection for the home, which included a site visit by an inspector and took place over one day, for a period of 7¼ hours. The service did not know that the inspector was to visit. During the visit care records were looked at as well as information about the staff, medication management and health and safety. The inspector also looked around the home as well as speaking with staff. Discussion and feedback was also held with the Registered Manager. As part of the inspection process the provider’s are asked to complete a selfassessment survey information document (Annual Quality Assurance Assessment). This was sent to the home before the inspection had been completed and returned to us prior to the site visit. Some of the information was limited or had not been completed. Discussion was held with the manager about developing this. Other information was gathered from the feedback surveys we sent out. We received completed surveys from 4 staff and a consultant psychiatrist. Comments have been added to the report. The purpose of this visit was to look at the key standards and any progress made following our last visit. What the service does well: Brookfield is a large home in a quite residential area of Prestwich and provides spacious accommodations for people living there. Since our last visit some new people have moved into the home and some long-term members of staff have left however people have remained stable and continue to be supported by regular members of the team. The team have good working relationships with health care professionals who regularly visit the home offering additional support and advice when needed. A feedback survey was received from a consultant psychiatrist who visits the home. Their comments included; ‘it is a suitable care home for people with long term needs who are unlikely to move to independent living’, ‘staff always up to date’, ‘calm and predictable environment’, good supervision of medication and mental health needs’, ‘support people in meeting health care needs’ and ‘good assistance and management of people who present with a risk of aggression’. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 6 Feedback was also received from 4 staff members, which were positive about the support provided, communication between the team and that they were able to carry out their role properly. One person also commented, ‘we maintain a good, lively environment and the home is very clean. What has improved since the last inspection? What they could do better: A letter has been sent to the provider with regards to work needed to the outside of the home and information about monitoring visits. These issues have been outstanding for some time. The provider has been requested to respond by the 4 April 2008 stating what action has been planned or taken. Information recorded in the care plans needs to be expanded upon to include all relevant support needs including areas of potential risk and how they are to be minimised. The manager is asked to provide a copy of the annual training plan for the forthcoming year showing what training opportunities are to be provided for staff around meeting the specific needs of people living at the home. A more robust system of gathering information when recruiting new staff needs to be put in place ensuring that all relevant checks and information are received prior to people commencing their employment. This will ensure that people living at the home are not placed at risk. Consideration needs to be given with regards to the management of staff hours ensuring some members of the team do not work an excessive number of hours. The manager is asked to provide us with a copy of the homes refurbishment and redecoration plan for the forthcoming year. The manager is to undertake a quality audit including sending out feedback questionnaires to people involved with the service. Once all information is received this is to be developed into an annual report. A copy of this should be sent to us. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 7 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 Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is gathered as well as people having opportunities to visit the home as part of the assessment ensuring people are only placed at the home if their needs can be met. EVIDENCE: Since our last visit two new people have moved into the home. As part of the assessment process each person was able to visit the home spending time with staff and other people living at the home. This included overnight stays as well as day visits. Assessment information was also provided. This was looked at and included nursing report, reviews in line with the care programme approach (CPA), tribunal notes, medical summary and discharge summary. Where someone had been admitted to the home following agreement by the mental health tribunal details were also available within the file of any conditions and support to be provided. Information was found to be detailed providing a good overview of the person mental health history, medication, support needs and potential areas of risk. From discussions with staff both people appeared to have settled well at the home. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Detailed information needs to be recorded within the care plans and risk assessments so that staff are fully aware of the needs of people and areas of potential risk are minimised. EVIDENCE: Care plans and assessment were examined for the two new residents. As already identified information provided at the initial assessment was comprehensive and clearly outlined the needs of people along with areas of potential risk. This information however had not been transferred to the care plan. Information seen did included information about peoples support needs in relation to their personal care, alcohol, health and family contact however plans were incomplete and did not evidence the goals or outcomes for people. A risk assessments form had also been completed exploring areas of daily living, medication and health. This showed whether the risk was low, medium Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 11 or high however there was no other information to show how this decision had been made or what intervention was required where necessary. Where specific areas of concern had been identified within the assessment such as substance misuse, self-medication, aggressive behaviours as well as conditions of placement, these to should be assessed and information detailed within the plan about how they are monitored. A number of people living at the home are placed there under a formal aftercare programme. This is monitored by mental health professionals through periodic reviews and visits to the home. Strategies are in place should concerns be identified and the placement be affected. This information should also be clearly detailed on the care plan so that staff are fully aware of the support and action to be taken. This will ensure the safety of all those living at the home. People living at the home are able to clearly express their needs and wishes. Each make decisions about their lives and what support they require. Records are completed with each person and the staff member they have requested as their key worker and is reviewed on an annual basis or as needs change. Further discussion are held on an informal basis with staff each day as well as in more formal meetings such as reviews with mental health professional. Individuals are aware of any restrictions in place and of the consequences should these be breached. People living at the home made the inspector feel very welcome. Individuals spent time relaxing in the lounge or in their own rooms. Interactions with staff were relaxed and friendly. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to live their lives as they choose. This could be enhanced by providing further opportunities and encouragement to follow other interests and activities enabling people to develop their confidence and skills. EVIDENCE: Arrangements in relation to the lives and routines of people at the home remain the same depending on their needs and wishes. A number of people choose to spend their time at home relaxing, watching television, reading papers or listening to music. Some of the people get involved with household tasks, including cooking, cleaning and laundry. Other follow interests away from the home accessing the local and wider community. Each have a bus pass enabling them to travel independently. A number of people still attend therapeutic employment. Staff continue to offer encouragement in maintaining their independence. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 13 The manager recognises that this is an area, which could be improved and is to explore this with the staff and people living at the home. This should involve looking at what interests people have and how staff can provide further support and encouragement affording people more opportunities and quality to their lives. People continue to maintain contact with family and friends. Visits generally take place away from the home, which are encouraged so that people have positive relationships and support from others. As previously identified residents have keys to their bedrooms however keys to the front door are not routinely given out, as staff are always available. The home has a large kitchen, which is suitably equipped and clean. Additional dry and frozen goods are stored in the cellar. Meals are generally prepared and cooked by the staff. The menu for each day is displayed on the board in the kitchen. An alternative would be provided should this be requested. On the day of the visit breakfast was cereal and toast or crumpets and beans, lunch included soup and sandwiches and the evening meal was pizza and chips followed by apple pie and custard. People are able to make themselves a drink and snack as and why they choose. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported in a way that ensures their emotional, physical and personal care needs are met. EVIDENCE: On-going support is provided to ensure that the health and wellbeing of people living at the home is maintained. Staff are supported by the mental health team. Visits are made to the home on a regular basis by mental health professionals such as community psychiatric nurses (CPN’s) and a consultant psychiatrist. This provides opportunity for the emotional/mental health needs of people to be monitored and reviewed, particularly where a formal agreement is in place in relation to their placement at the home. Feedback from a visiting consultant was positive about the care and support provided. Comments included; ‘it is a suitable care home for people with long term needs who are unlikely to move to independent living’, ‘staff always up to date’, ‘calm and predictable environment’, good supervision of medication and mental health needs’, ‘support people in meeting health care needs’ and ‘good assistance and management of people who present with a risk of aggression’. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 15 Consideration is given to the changing needs of people. One person has since our last visit moved to another home, which was felt to be more suitable in meeting his needs. Another person has moved into their own accommodation in the local community. Where additional support is been required, the team would access occupational therapy, district nurses etc for further support and advice. People also have access to other NHS entitlements such as GP’s, hospital, dentist, optician etc. Where support is required at appointments this is provided. Rising and retiring times continue to be flexible, this was noted during the visit. Residents are able to manage their own personal care needs however staff will prompt and offer encouragement where necessary. Residents are also able to move around freely and do not require any physical support. The medication system was looked at. Items are stored safely and records are made of all items received as well as those returned to the supplying pharmacy. The supplying pharmacist also audited the system in August 2007, no issues were identified. Where necessary people attend clinic for blood tests to ensure that they in receipt of the correct medication and dose. Relevant information is then recorded on the MAR sheet. Two people living at the home take responsibility for their own medication. Both staff and the person sign the MAR sheet to evidence that items have been provided. Individuals also sign a form to state whether they wish to self medicate or receive support. For those people self medicating no risk assessment had been carried out to determine that they were able to manage this safely. Information had not been detailed on the plan to show how this was to be monitored ensuring the system was safe. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures regarding complaints and adult protection are in place along with staff training. This ensures people are listened to and protected. EVIDENCE: Policies and procedures are held with regards to complaints and protection. A copy of the local authorities safeguarding procedure is also available within the home. Whilst staff have received training in this area this has not been specific to the local authority procedure. The manager may wish to incorporate this in the training plan for the forthcoming year. On examination of one of the care files it was found that the complaints procedure did not provide up to date information about how to contact us. This should be updated. From information provided no formal concerns or complaints have been raised within the home or directly with CSCI. A random check was carried out in relation to residents finances. All but 1 residents takes responsibility for their finances. Individuals also have their own savings accounts. Where residents are supported with a budget plan, this information is recorded and records are made of all transactions. Money held was checked against the records and found to be correct. Other areas in relation to safeguarding such as recruitment procedures need to be improved these have been outlined further within the report. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Brookfield provides spacious accommodation however work is needed to both external and internal parts of the home so that people live in an environment, which is safe and well maintained. EVIDENCE: Since our last visit there have been no changes to the environment. This home is a large detached property situated in a quiet residential area of Prestwich. It is set in its own grounds with a well-maintained garden and patio to the rear and a small seating area and car park area to the front. The home has 3 full bathrooms including toilets and two separate toilets, one of which has been designated for the staff. There are 14 single bedrooms each have the provision of a wash hand basin. The accommodation also comprises of a large lounge, which is the designated smoking area, a dining room, kitchen and separate laundry. A staff office/sleep-in room is available on the ground floor. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 18 People living at the home are able to access all local amenities and the public transport systems provided in Bury, Prestwich and Manchester. During previous visits concerns have been raised with regards to damage being caused to the outside of the property due to pigeons. Whilst some attempt has been made to resolve the problem the issues still remain. Parts of the property are heavily soiled, the fascias and guttering are damaged and a whole has now developed in the bay above one of the bedrooms. This is not acceptable. A letter has been sent to the provider requesting that we are informed in writing by the 4 April 2008 of the action to be taken to resolve the matter and make good the damage caused. Other areas of the home were looked at. It was found that the hall, stairs and landing carpets were worn and tired looking and wallpaper was beginning to peel away. Two bedrooms had recently been repainted however some of the carpets were soiled and required cleaning or replacing. The upstairs bathroom required attention as the flooring was marked, the shower needed grouting and the bath mat replacing. The manager said that new furniture was to be provided within the dining room. The manager was asked to develop a redecoration and refurbishment plan, showing what areas of work have been identified and proposed timescales for completion. A copy of the plan is to be forward to us. The home continues to employ a designated worker who carries out the majority of domestic tasks, however people living at the home and other support staff carry out additional tasks. During the visit the home was seen to be clean and generally odour free. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff must be provided in sufficient numbers and be robustly recruited so that people living at the home are not placed at risk. EVIDENCE: The staff team had remained stable until December 2008. The two regular night staff members have now left the home. The current team comprises of the manager, 4 carers, one of whom has very recently been recruited and a domestic, who at times will cover support shifts. The manager and one of the a carers are covering the night shifts. The carer is currently undertaking 6 of the sleep in shifts each week and 2 day shifts. This is excessive and alternative arrangements should be explored with other members of the team until more suitable long-term arrangements have been made. The manager is at present trying to recruit more staff. One person has recently been employed however they are just 18 years of age and therefore unable to work the night shift. A further person was interviewed during our visit. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 20 The recruitment file was looked at for the newest member of the team. Information included an application form with full employment history, references, contract and induction information. It was noted that the persons start date was the 6 February 2008 however one reference was dated 19 February and the other not dated, but had not been requested until the 13 February 2008. The was no evidence of a POVA 1st check or criminal record check having been completed. This practice is unsafe. The manager must ensure that all relevant information and checks are completed and information is held on file prior to any new staff commencing their employment. Through discussion with the manager it appears that the home does not access the POVA 1st checks as an interim measure. This mean any new staff are not able to commence until the full check has been carried out and received by the home, causing a delay in people starting work. Discussion was held with the manager with regards to staff training. At present the home is not a member of the local authority training partnership group, which provides this type of training through Skills for Care. Details of how to contact the partnership were given to the manager. Further training has been provided in food hygiene, adult protection and fire safety, which had been required at the last inspection. The manager is to explore the training needs of staff and develop a training plan for the forthcoming year. A copy of this is to be sent to us. In relation to NVQ training, the Manager has recently completed the Level 4 Registered Managers Award. Training in level 2/3 has also been completed by all but one member of the team. One carer also holds the Assessors Award. Further training in this area would need to be offered to all new members of the team. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 29 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home remains consistent and reliable for the people living there. However systems still need to be developed with regards to reviewing the service provision and sharing information about the well-being of people living at the home. EVIDENCE: The manager has worked at the home for many years. He has considerable experience of working with people with mental health needs and has completed his NVQ level 4 and Registered Managers Award. Copies of the certificates have been requested. Time was spent talking with the registered manager about the process for Inspecting for Better Lives, including quality ratings, annual reviews and AQAA. The home does not have a computer, which has internet access and therefore Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 22 is not able to readily access relevant information. This would be of benefit for the home in relation to accessing information as well as working with other organisations. The manager has yet to complete the Nation Minimum Data Set for Skills for Care. The registered provider has still not undertaken the monthly Regulation 26 monitoring visits. This has been outstanding from previous inspection visits. The manager told us that one had been planned for the forthcoming week. A letter has been sent to the provider stating that the report must be forwarded to us be 4 April 2008. Visit must be carried out on a monthly basis in line with the Regulation and a copy of the reports sent to us each month. We also discussed other areas of quality monitoring with the manager. He explained that questionnaires are to be sent out to people involved with the service including people living at the home, their relatives and health and social care professionals. Once information has been received this is to be collated into an annual report looking at what the home provides, what areas could be improved and how they are to do this. A copy of this report should be sent to us. Discussion was also held with the manager with regards to reporting incident in line Regulation 37. Since our last visit an incident occurred involving a prospective resident, one person went missing for a period of time and another person passed away. This information must be recorded and forwarded to us so that we are aware of event taking place and action taken ensuring people are safe. A sample of other records were looked at with regards to health and safety. Checks had been carried out on the gas, electric circuits, fire alarm, emergency lighting, small appliances and fire equipment. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15(1) Requirement The Registered Person must ensure that the care plan is developed to fully reflect the skills, abilities and support needs of residents. (Requirement not met – 31/1/07) Timescale for action 30/04/08 2. YA9 13 The Registered Person must 30/04/08 ensure that where areas of risk/concern have been identified that this is assessed and incorporated into the care plan. (Requirement not met – 31/1/07) A risk assessment should be completed for those people who manage their own medication ensuring the system is safe. The provider must confirm in writing the action to be taken to address the health and safety issues affecting external parts of the home and the damage caused. (Requirement not met – 31/3/06 & 31/1/07) 30/04/08 3. YA20 13(2) 4. YA24 13(4) 04/04/08 Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 25 5. YA33 18(1) Action should be taken to ensure that staff do not work excessive number of hours. The manager must ensure that all relevant information and checks are held on file prior to new staff commencing their employment ensuring people are not placed at risk. 31/05/08 6. YA34 19(1) 31/05/08 7. YA39 26 The Registered Person must 04/04/08 ensure that monthly reports are undertaken as outlined within the Regulation and copies are forwarded to the CSCI. (Requirement not met – 31/5/05, 31/1/06 and 31.12.06). The manager must ensure that the commission is notified of any incidents, which may affect the well-being of people living at the home. (Previous recommendation) 30/04/08 8. YA42 37 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. Refer to Standard YA11 YA12 YA24 YA35 Good Practice Recommendations Consideration should be given to discussing, planning and providing opportunities for people to A copy of the home redecoration and refurbishment plan should be forwarded to the CSCI. A training plan should be developed to include courses specific to the needs of people living at the home. A copy of the plan should be forwarded to CSCI. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 26 4. 5. 6. YA37 YA39 YA42 The manager should forward copies of certificates to CSCI evidencing the completion of the Level 4/RMA. Once completed a copy of the homes annual assurance report should be sent to the CSCI. The Registered Person should ensure that the Regulation 37 notification is forwarded to the CSCI in relation to an accident or incident, which may affect the well-being of a resident. Brookfield Residential Care Home Limited DS0000008454.V349144.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Residential Care Home Limited DS0000008454.V349144.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. 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