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Inspection on 28/02/06 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 28th February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 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

Residents living at the home are very settled and have lived at the home for a number of years. Staffing has also stayed the same offering a stable home and level of support. Both staff and relatives have developed good relationships with each other. Brookfield is a large home and offers residents roomy accommodation in a quite area of Prestwich. Residents enjoy a relaxed routine in quite surroundings and have help and support were needed. The home continues to be supported by the local mental health team. Staff have built up good working relationships with them so that residents health and well-being is maintained. Residents spoke with expressed that they were settled at the home. One residents who had planned to move on had decided to stay at eh home stating that he felt `safe living at the home` and `liked having staff around to help`.

What has improved since the last inspection?

Work has been carried out to the living areas within the home. This has improved the appearance of the rooms providing clean and bright accommodation for those living there. Training has also been done by the staff in relation to mental health needs, this has provided them with further knowledge and an insight into the needs of those people the support.

What the care home could do better:

On-going training is still needed, this includes vulnerable adults, fire safety and food hygiene. The manager is to arrange this so that staff are aware of procedures to follow ensuring the safety and protection of residents. Outside of the home still needs some attention. The on-going problems with pigeons, which have caused some areas to be heavily soiled, need to be addressed for the health and safety of the residents and staff, it would also enhance the appearance of the home. The manager is aware of other work needed to the home. The manager is to write a plan of work showing what needs to be done and when they hope to complete.

CARE HOME ADULTS 18-65 Brookfield Residential Care Home Limited Brookfield St Anns Road Prestwich Manchester M25 9QE Lead Inspector Lucy Burgess Unannounced Inspection 28th February 2006 09:00 Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 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.V284694.R01.S.doc Version 5.1 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.V284694.R01.S.doc Version 5.1 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.V284694.R01.S.doc Version 5.1 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. 22nd August 2005 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 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.V284694.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place over one day for a period of 5 hours. The inspector took the opportunity to look round the home, view records and policies as well as talk with a number of residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for 14 people. There were no vacancies. What the service does well: What has improved since the last inspection? Work has been carried out to the living areas within the home. This has improved the appearance of the rooms providing clean and bright accommodation for those living there. Training has also been done by the staff in relation to mental health needs, this has provided them with further knowledge and an insight into the needs of those people the support. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 6 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 Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 7 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.V284694.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 The system of assessing prospective residents as well as spending time with them prior to admission gives an assurance that a resident will only be admitted if the home can meet their needs. EVIDENCE: Residents living at Brookfield have lived there for some time. However following the recent loss of a resident a new placement has recently been made. Placements are arranged and agreed with relevant health and social care professionals. Assessment information is requested from those health and social care professionals involved in assessing the mental health and support needs of individuals. The home also encourages prospective residents to visit the home. This enables both residents and staff to meet with each other as well as enabling further information to be gathered about their particular support needs, before making a decision in relation to the suitability of the placement. On examination of the file for the newest residents information was seen to be held on file. This had been used to inform the development of the care plan. Placements are reviewed following an initial period and then on an on-going basis as part of the discharge programme ensuring needs are being met. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 and 9 Care plans and risk assessments were detailed, up to date and reflected the care needs of residents providing staff with clear information about how their needs should be met. Residents expressed they were well cared for and were clearly involved in making decisions about their lives. EVIDENCE: Individual files are held for each of the residents. As the majority of residents have lived at the home for a number of years some information has been archived. This includes the initial assessment information as well as review notes and old care plans and assessments. Working files are in place and are accessible to staff each day. Information includes and up to date care plan and risk assessments, which focus on current needs, maintaining independence and developing new skills. Information had been gathered for the newest resident. This identified what areas the residents required support, further information had been detailed in relation to any areas of risk to be considered. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 10 Risk assessments focus on issues related to individual abilities, health needs and the environment. Where a concern has been identified this would be detailed further within the care plan. Plans seen had been reviewed and updated by the staff team. The mental health needs of residents has been very stable. Formal reviews continue to be held with mental health professionals, ensuring their health is maintained and any changes noted can be monitored and additional support provided. As previously identified the majority of residents are placed at the home under formal discharge programmes, which have been agreed by mental health professionals and the home office. Any serious concerns identified could result in residents being returned to hospital ensuring risks are minimised and individuals are protected. Staff at the home also complete daily records, which are also used for monitoring purposes, this information is used within the formal and informal reviews of care. Additional records are also held with regards to finances and medication. Each of the residents are involved in the development of such information aware and are asked whom they would like as a key worker. Together they would be involved in reviewing and updating of care plans. Records seen had been signed by the residents to evidence their involvement. Information is held securely within the staff office and easily accessible to staff. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. This method is preferred rather than formal meetings. From feedback received and through observations made residents are relaxed happy with the support provided and interactions with staff were seen to be open and friendly. One resident who has decided to remain at the home commented that he felt ‘safe living at the home’ and ‘liked having staff around to help’. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 to 17 Routines vary depending on individual choices and preferences. Residents access the local and wider community enabling them to lead valued lives, develop skills and increase their independence. Support is offered where required. Residents maintain contact with family and friends and open visiting is encouraged. The meals are good and offer choice, providing residents with a varied diet. EVIDENCE: Each of the residents living at Brookfield have routines based on their own choices and preferences. Whilst some individuals prefer to spend the majority of time at home, watching television, reading papers, using the computer, listening to music and relaxing, others follow interests away from the home. Rising and retiring times vary depending on individual routines or motivational levels. Residents pursue activities both in and away from the home accessing the local and wider community. Staff offer encouragement in maintaining their independent living skills. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 12 The home is a large property and indistinguishable from those around it. The home is easily accessible to Prestwich town centre and a short distance from Manchester City Centre. Residents have bus passes and one individual has his own car. Support at the home is offered throughout the day over seven days a week. Some of the residents access college courses, whilst others undertake therapeutic employment. The newest residents has enrolled in a course covering Buddhism and another has a job at a local charity shop. Each of the residents are encouraged to develop and maintain their independent living skills. Some of the residents are involved with household tasks, including cooking, cleaning and laundry. Support is provided where required. A few individuals have ‘designated’ jobs within the home for which they receive a small ‘wage’. Other activities undertaken by the residents include visiting the cinema, shopping at tesco’s, attending synagogue and church or attending the chess club. Occasional trips are also provided. Contact with family and friends is also encouraged. Visitors are welcome to visit Brookfield at any time. Individuals are able to see visitors in private using the dining room or their bedrooms. As previously identified residents have keys to their bedrooms however keys to the front door are not routinely given out, this is due to risk and the home is always occupied. One resident does have a key as he arrives home at various times depending on his activities or religious festivals. Meals at the home are flexible. As routines vary individuals take breakfast and lunch at different times or away from the home. Meals are generally provided by staff however some individuals will provide assistance undertaking certain tasks. The home has a large kitchen, which has been refurbished and recently inspected by the food premises inspector. No action was identified. Meals provided during the visit included hash brown and beans, soup and sandwiches and chicken, potatoes and vegetable. Other options were available for pudding and supper. Individuals are able to access the kitchen throughout the day to make drinks and snacks should they wish. Information is recorded in relation to meals served, food temperatures and fridge and freezer temperature. Additional food storage is available in the basement. The home has a separate dining room where individual take their meals. Cultural/religious preferences are also catered for. One service user follows a kosher diet. Arrangements are made for food to be purchased and separate cooking implements are in place. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents health and personal care needs are consistently met ensuring their well-being is maintained. Relationships with mental health professionals are effective and provide positive support networks for the residents ensuring their health needs are promoted. The medication system was found to be safe and staff have completed training ensuring residents are protected and practice is safe. EVIDENCE: As stated earlier information regarding the health needs of residents are identified within the care plans. Where specific areas of risk have been identified these too have been assessed and information held on file. Records are made of all professional visits and appointments, which include GP’s, hospital, epilepsy clinic, nurse clinics etc. Each resident has access to all NHS entitlements as and when they are needed. Support is offered for appointments where necessary. As already stated the emotional/mental health needs of residents are monitored and reviewed by relevant mental health professionals during regular review meetings. Individuals continue to be monitored through the Care Programme Plan. The mental health and well-being of residents is stable, Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 14 where changes are noted additional advice and support would be sought from those health professionals involved in delivering the care. Evidence of reviews with community psychiatric nurses (CPN’s), Consultants, Social Workers and Probation etc are held on file. Rising and retiring times are quite flexible. 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, therefore no aids have been fitted. The medication system was examined. The storage and recording of medication was found to be safe. Records are made of all items received at the home as well as those returned to the supplying pharmacy. A recent audit has been carried out by the supplying pharmacist, no concerns were identified. No controlled drugs were held on the premises nor was medication being stored within the fridge. From observations made staff observe residents taking their medication whilst in the office, records are then completed, ensuring practice is safe. Where necessary several residents attend clinic to visit the nurse in order for blood tests to be taken and appropriate levels of medication prescribed, or so the effects of medication can be monitored ensuring residents received the appropriate care in maintaining their health. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Satisfactory arrangements are in place in relation to the protection of service users as well as responding to their concerns. Policies are in place outlining the appropriate response for allegations of abuse. However training is outstanding in this area, to ensure that staff are aware of what action to take, so that service users are protected. EVIDENCE: As previously identified information is provided in relation to the complaints procedure. Copies of the documents have been included within the Residents handbook, which have been distributed to all residents. A system is in place for recording any issues. No complaints have been raised at the home or with the CSCI. The home holds a copy of the Local Authorities Adult Protection procedure and all staff, other than the manager have completed training in this area. This is to be arranged ensuring the safety and protection of residents. As previously identified residents needing support with finances are assisted. At present only 3 residents are supported in managing their finances. Records are made of all transactions. The majority of residents continue to have their own bank accounts where money is deposited and managed independently. Individuals also have their own savings accounts. Other policies are in place for the protection of the service users, these include; accidents, emergencies, whistle blowing, management of service users finances, missing persons and risk management. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Brookfield provides a comfortable and homely environment for the residents living there, however would benefit from some refurbishment to the interior and exterior of the home further enhancing the property as well as addressing issues affecting the health and safety of residents and staff. EVIDENCE: Brookfield is situated in a quiet leafy residential area of Prestwich. The home is detached and offers spacious accommodation for those who live there. outside space. Accommodation is provided on 3 levels. There is a large lounge, which is the designated smoking area, a dining room, kitchen and separate laundry. There is a staff office/sleep-in room available on the ground floor. The home also has 3 full bathrooms including toilets and a separate toilet, which has been designated for the staff. Two further toilets have been provided on the ground and 1st floor. Each have been fitted with suitable locks to offer privacy. Bedrooms have the provision of a wash hand basin and are single occupancy. The home is set in its own grounds with a well-maintained garden and sitting area to the rear of the property. There is also a small seating area and car Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 17 park area to the front of the home. Brookfield is situated close to local amenities and public transport between Bury, Prestwich and Manchester. The property is in keeping with other in the area. The home has recently been decorated in several areas. One of the bedrooms the lounge, dining room and upstairs landing have recently been redecorated. New furniture has been purchased for a bedroom, lounge and dining room. As previously identified the kitchen has been refurbished. This has made an improvement to the environment. Rooms looked clean and bright and provide comfortable communal space for the residents. Further work within the home has been identified. The manager is asked to write a plan of work outlining timescales for completion. As identified at the last visit attention is needed to the exterior of the building. The home has been having on-going problems with pigeons, which have caused some areas to become heavily soiled. Action should also be taken with regards to replacing the facia boards, repairs to the guttering and the leak within the 1st floor bay windows. Several of the old window frames also need painting. Appropriate action should be taken to address the above so as not to affect the well-being of residents as well as enhancing the appearance of the home. The home continues to employ a designated worker who carries out the majority of domestic tasks, however the support staff and residents carry out additional tasks. During the visit the home was seen to be clean and generally odour free. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 A programme of training has been identified to equip staff with the knowledge and skills needed in meeting the needs of service users. Recruitment and selection procedures are followed and checks have been carried out ensuring that the service users are protected. EVIDENCE: Staffing at the home has been consistent with no further recruitment since the last inspection, therefore offering consistency. Individual staff files are held and contain all relevant information and checks required ensuring the protection of the residents. Staff have a good understanding with regards to the support needs of individuals. Recent training has been provided with regards to Mental Health enabling staff to develop their knowledge in relation to the needs of the residents. One member of staff has also completed training with regards to diabetes. Further training is still required in relation to fire safety, food hygiene and adult abuse. The manager is to make arrangements for staff to attend such training ensuring that all have completed the courses. Several members of staff are also completing the NVQ training. Currently 2 staff are completing the level 2. A third member of staff has undertaken the assessor’s award and is now undertaking a NVQ level 3. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 19 The manager has also undertaken periodic supervisions with the staff team. Discussions include resident’s needs and routine as well as areas of training and development. Team meetings are held every 2nd month and information is recorded. Further support is provided through daily interaction by the manager with staff offering advice and support where necessary. Staff spoke with were happy working at the home and felt fully supported in their role. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The overall management of the home is consistent and reliable for the people living there. Systems are in place for the reviewing of the service provision ensuing the home meeting the identified needs of residents. Satisfactory arrangements are in place with regards to providing a safe, well maintained home so that residents and staff are safe from harm. EVIDENCE: The Residential Manager has worked at the home for a number of years and has a good understanding of the needs of the residents. The manager is currently completing the NVQ Level 4/Registered Managers Award. Other training courses related to the needs of residents have also been completed ensuring that his practice is up-to-date. The Registered Provider of the home also offers informal support to the manager. Monitoring visits required in line with Regulation 26 are still not undertaken by the Registered Provider, this should be addressed and copies of the report forwarded to the CSCI. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 21 Feedback from stakeholders with regards to the overall service provided is gathered in a number of ways. Residents have day-to-day contact with the manager and staff and feel able to discuss any matters or ideas they have. Residents meeting are also held. Feedback is sought from the staff during the periodic team meetings and supervisions. Additional comments are also received during the residents review meetings, which involve health and social care professionals. Regular checks are undertaken ensuring the safety of staff and residents. Up to date certificates were in place for • 5-year electric checks, • fire appliances and alarm, • emergency lighting • small appliances. An annual check with regards to the gas servicing could not be found. The manager must ensure that this is undertaken and a copy of the certificate held on file. A recent visit on the 10 January 2006 has taken place from the Food Premises Inspector, no action was identified. The home also complete records with regards to food and fridge/freezer temperatures. Further in-house checks are also made with regards to sounds to fire safety and the general environment and. Coshh and general risk assessments also need to be reviewed and updated. The home must also purchase an accident book ensuring all incidents are recorded appropriately. Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 22 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 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. 2. 3. 4. Standard YA23 YA24 YA35 YA37 Regulation 13/18 13/23 18 26 Requirement That all staff complete training in the Protection of Vulnerable Adults That action is taken to address the health and safety issues to the exterior the home That all staff complete training in fire safety and food hygiene. That monthly reports are undertaken as outlined within the Regulation (previous timescale of 31.5.05 not met) That an annual gas check is carried out and certificate placed on file Timescale for action 31/03/06 31/03/06 31/03/06 31/03/06 5. YA42 13 31/03/06 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 YA24 YA42 Good Practice Recommendations That a refurbishment plan is developed and a copy forwarded to the CSCI That the Coshh risk assessments are reviewed and updated DS0000008454.V284694.R01.S.doc Version 5.1 Page 24 Brookfield Residential Care Home Limited 3. YA42 That a new accident and incident book is purchased Brookfield Residential Care Home Limited DS0000008454.V284694.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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