Inspection on 07/11/06 for Brookfield Residential Care Home Limited

This inspection was carried out on 7th November 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brookfield Residential Care Home... 26/04/10

Brookfield Residential Care Home... 24/03/09

Brookfield Residential Care Home... 25/03/08

Brookfield Residential Care Home... 28/02/06

Brookfield Residential Care Home... 22/08/05

Brookfield Residential Care Home... 07/03/05

Brookfield Residential Care Home... 18/08/04

Brookfield Residential Care Home... 03/02/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOME ADULTS 18-65 Brookfield Residential Care Home Limited Brookfield St Anns Road Prestwich Manchester M25 9QE Lead Inspector Unannounced Inspection 7th November 2006 10.30a Brookfield Residential Care Home Limited DS0000008454.V297674.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.V297674.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.V297674.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.V297674.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. 28th February 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 £339.00 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.V297674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day for a period of 5½ hours. The inspector took the opportunity to look round the home, view records as well as talk with residents and staff. Discussion and feedback was also held with the carer on duty. A pre-inspection questionnaire was completed and feedback surveys were received from a CPN and a Social Worker. Comments have been included within the report. The home is registered to provide accommodation for up to 14 people with mental health needs. At the time of the inspection there were no vacancies. What the service does well: Brookfield is a large detached Victorian house in a residential area of Prestwich. The home is set in it’s own grounds and overlooks the ‘Clough’ area. Residents have easy access to all areas of the home as well as the enclosed private rear gardens. Most of the residents have lived at the home for some time and have developed good friendships with each other. There has also been no staff turn for some time further offering residents a stable home environment. The Manager and support staff have good working relationships with health and social care professionals and will ask for advice and support when needed making sure that residents are well cared for. Both residents and staff expressed that they were settled, felt supported and happy at the home. Staff also expressed they fully felt fully supported by the Manager. Feedback received from the CPN and Social Worker confirmed that they were able to see residents in private, that there was clear communication, that information was included within the care plans and that medication was appropriately managed. Staff spoken with felt that there were good relationships between the team, with trust and respect for each other and that each where willing to help. The Manager was also described as being ‘a good boss with lots of compassion’. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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.V297674.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relevant assessment information is gathered prior to individuals moving in. The enables the prospective residents and staff to make an informed decision about the suitability of the placement ensuring needs can be fully met. EVIDENCE: Brookfield is very settled with residents having lived at the home for sometime, therefore no new admissions have been made. The process of referral and admission followed by the Manager involves sourcing all relevant information including medical history and assessments from relevant health and social care professionals. Placements are made under formal arrangements under the Mental Health Act therefore are well planned with a clear reviewing process in order to ensure that the placement is suitable for all parties. Time is also spent meeting with prospective residents’. This can involve visits to their home or hospital etc. Individuals are also encouraged to visit the home to meet with other residents and staff. This would take place over a period of weeks or months depending on the individual. Care is taken in ensuring that placements are suitable and that staff are able to meet the needs of the individuals. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. 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. Care plans and risk assessments are updated and reviewed on a regular basis with the involvement of residents however information needs to be expanded upon to ensure that areas of support and risk are detailed and reflect the current support needs of residents. EVIDENCE: Care files were examined for 2 of the residents where issues had been identified. Through discussion with the staff on duty it was noted that the personal care needs of one resident had changed resulting in a more suitable placement being sought and the second resident was demonstrating changes in behaviour, mood and health. Both issues had been referred to the relevant health and social care professionals involved. For the first resident and assessment had been carried out by the occupational therapist in relation to specific tasks followed by a needs assessments by the social worker. It was agreed that due to the care needs of the resident that Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 Page 10 alternative accommodation was to be explored. At each stage the resident has been actively involved and consulted with. The second resident had also been seen by the occupational therapist so that an assessment regarding daily living skills could be undertaken. Regular visits also take place with the CPN (Community Psychiatric Nurse). Recent health issues have arisen with regards an eating disorder. This has been discussed with the consultant within the CPA reviews and is being monitored. It was also discussed that the resident’s routine and mood had changed and was sleeping for long periods during the day. Considering these issues it was found that little had been transferred to the care plans. Information regarding the first resident did not provide any detail with regards to his epilepsy, recent falls and the impact on his physical health nor had a detailed risk assessment been completed regarding the seizures and falls. For the second resident, the care plan stated that the resident was generally self caring and required little support from staff, there was not information with regards to the changes in health and monitoring taking place or the agreement in relation to managing the alcohol intake. The resident had also been asked by the social worker to complete a diary in relation to his routines and activities, this had been refused. Whilst notes had been made within the daily diaries, further details had not been added to the plans. Up to date general risk assessment were also not found in either of the files. Although plans are reviewed on a 6 monthly basis the Manager must ensure that were needs have changed that a further review is held and information is updated to reflect the current needs. The inspector chatted with several residents. All were very welcoming. Residents were very relaxed, each felt they were well cared for. One resident was unsure about whether to move into his own accommodation, this was something he said he would talk to the staff about before making a decision. Interactions between residents and staff were relaxed and friendly. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents continue to follow a lifestyle of their choosing, both in and away from the home. The meals are good and offer choice, providing residents with a varied diet. The cultural and religious needs of residents are also met. EVIDENCE: Residents living at the home vary in age, as do their routines. Whilst some individual prefer to spend the majority of time at home, watching television, reading papers, using the computer and relaxing, others follow interests away from the home accessing the local and wider community. Staff continue to offer encouragement in maintaining their independent living skills. A number of resident continue to attend therapeutic employment and another is a member of a gym and local chess club. Each of the residents have a bus pass enabling them to travel independently and one resident has his own car, which affords him further independence. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 Page 12 Some of the residents continue to be involved with household tasks, including cooking, cleaning and laundry. One resident had recent made a meal for himself and another resident. Individuals are encouraged to develop and maintain their independent living skills. Those residents choosing to also attend the local church or synagogue and specific festivals and holy days are observed. Suitable arrangements are made in relation to the Jewish dietary laws. Kosher food provisions are purchased along with the provision of separate cooking implements, crockery and cutlery. Residents continue to maintain contact with family and friends. In the main this takes place away from the home. Some residents spend weekends and overnight stays with family each week. This is encouraged as this enables residents to 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. One resident previously had a key however this was lost. Due to the potential risks identified a further key has not been provided. Weekly menus are in place with regards to meals. Generally all meals are provided by the staff although those willing to help do so. Breakfast usually consists of cereal and toast with a cooked breakfast available at weekends. A light lunch is provided with the main meal in the evenings. 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. As already stated that cultural/religious preferences of one resident are also catered for. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. 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. The health and well-being of residents are consistently met. The home continues to maintain effective relationships with mental health professionals who provide positive support networks for the residents ensuring their health needs are promoted. The medication system was found to be safe however minor improvements were needed to the records to evidence practice is safe. EVIDENCE: Consideration is given to supporting residents with their physical, emotional and mental health needs. As identified earlier in the report care plans and assessments need to be expanded upon to evidence what support is being provided to address current issues. On resident has recently been reassessed due to changing needs. Discussion has been held with the resident about an alternative placement and a visit has taken place. This was felt to be a more appropriate home as this will meet both the identified care needs as well as being a more suitable place to meet his cultural and religious needs. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 Page 14 Where additional support has been required, the team have accessed the mental health teams, occupational therapy, district nurses etc. Residents also have access to other NHS entitlements such as GP’s, hospital, dentist, optician etc. Where support is required at appointments this is provided. The emotional/mental health needs of residents continue to be monitored and reviewed by appropriate mental health professionals during regular review meetings. Whilst some residents are supported under the Care Programme Plan others are more informal. In the main residents mental health and wellbeing continues to remain stable. Rising and retiring times are quite 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 examined. Medication is stored safely and records are made of all items received as well as those returned to the supplying pharmacy. The Manager should ensure that were changes are made to the records tipex is not used and that written entries are countersigned and dated to evidence that the information recorded reflects that on the prescription. It was also found that two of the residents self medicate. The MAR sheet is signed by the resident and staff member showing that medication has been provided. The Manager has then previously monitored that medication is being taken properly on a monthly basis. This had not been done for two months. The Manager must ensure that the manner in which the check is carried out, what is checks and the findings are clearly recorded, showing that the residents are safe to self administer. On-going records should e provided. It was also noted that one member of staff had handled the medication when administering instead of placing the tablets in a small cup, this should be prevented. Two feedback surveys were received from visiting nurses. Both confirmed that the home works in partnership and clearly communicates individual needs, that staff demonstrate a clear understanding of individual needs, that medication is appropriately managed and that they are satisfied with the overall care. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. 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. The home holds clear procedures regarding complaints and adult protection, ensuring that residents were listened to and protected. Relevant training is being provided to all members of the team. EVIDENCE: As previously identified Brookfield holds policies and procedures with regards to complaints and protection. A copy of the Inter Agency Procedure for the protection of Vulnerable Adults is also available. All but 2 members of the team have completed training in the area. Manager is presently making arrangements for this to be completed. The Through feedback and discussion with residents and staff no issues or concerns have been raised within the home or directly with CSCI. A random checks 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, all balanced. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. 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 is a large domestic dwelling providing comfortable, homely environment for the residents. Outstanding work to the exterior of the property would further enhance the appearance of the home. EVIDENCE: This home is a large detached property situated in a quiet leafy residential area of Prestwich. It is set in its own grounds with a well-maintained garden and sitting area to the rear of the property and a small seating area and car park area to the front. The home also 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.V297674.R01.S.doc Version 5.2 Page 17 Residents have access to all local amenities and the public transport systems provided Bury, Prestwich and Manchester. It was noted during the last visit that external areas of the home required attention. The Manager informed the inspector that some cleaning had taken place with regards to the pigeons, however this had not resolved the problem. Work is also planned with regards to painting the front door, windows around the door and the patio area. This work does not include addressing the remaining windows, replacing the facia boards, repairs to the guttering and the leak within the 1st floor bay windows. Appropriate action must 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. Concerns were raised with regards to two residents and the condition of their rooms. The Manager and staff were aware of these. One of the residents has recently been reassessed and will be moving from the home due to changing needs. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is clear about his responsibilities when recruiting new staff. Training opportunities are provided. Additional courses are to be explored providing staff with further knowledge and skills to meet the needs of service users as well as ensuring their safety and protection. EVIDENCE: The team comprises of the Manager and 6 staff, one being the domestic. Support is provided throughout the day and evening. A minimum of two staff and the domestic are available during the day with sleep-in cover at night. There is also an on-call facility should additional support be required. Since the last visit no new staff have been employed, therefore providing residents with consistent and reliable support. Due to this and that the standard was met at the previous visit no recruitment files were not inspected on this occasion. Staff are provided with the mandatory training as and when required. Recent courses completed have include food hygiene and vulnerable adults. As already stated the Manager is making arrangements for the remaining 2 staff Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 Page 19 to complete the adult protection course. Further training is still required in relation to fire safety. The Manager is to follow up on this and make the necessary arrangements. Further discussion was held with regards to staff receiving training in relation to the specific needs of residents. Whilst some staff have, this was some time ago. The Manager is to explore this area. All staff have been trained in administering medication and 1st aid. Support is not required in moving and handling. In relation to NVQ training, the Manager has recently completed the Level 4 Registered Managers Award. One carer holds the level 3 and the Assessors Award and another level 2. The remaining staff that do not hold this certificate complete all relevant mandatory courses. Staff spoken with felt that there were good relationships between the team, with trust and respect for each other and that each where willing to help. The Manager was also described as being ‘a good boss with lots of compassion’. Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 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 is consistent and reliable for the people living there. Systems need to be developed with regards to the reviewing of the service provision. Satisfactory arrangements with regards to providing a safe environment however could be improved in some areas. EVIDENCE: As previously identified within the report, management and staffing arrangements have remained unchanged. The Manager has now completed the level 4/Registered Managers Award, he is requested to forward copies of his certificates to CSCI. The Registered Provider who supports the manager in his role, makes periodic visits to the homes. Monitoring visits required in line with Regulation 26 are still not undertaken by the Registered Provider, this has been an outstanding Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 Page 21 requirement for some time and should be addressed as part of the home quality monitoring. Further discussion was held with the manager in this area in relation to further feedback being sought from other stakeholders with regards to the overall service provided. The Manager is to explore this area. 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. Information was provided on the pre-inspection questionnaire with regards to health and safety checks. Details were confirmed during the visit and up to date certificates were in place. Further in-house checks are carried out by st6aff within the home with regards to fire safety and the general environment Coshh and general risk assessments had been reviewed and updated. An accident book had also been purchased as identified during the last visit. One incident had been recorded, this involved one resident who had attended A & E following a fall whilst in the community. This information should be provided to CSCI in line with Regulation 37. Brookfield Residential Care Home Limited DS0000008454.V297674.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 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 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 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 2 X 3 X 2 X X 2 X Brookfield Residential Care Home Limited DS0000008454.V297674.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 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. Timescale for action 31/01/07 2. YA9 13 The Registered Person must 31/01/07 ensure that where areas of risk/concern have been identified that this is assessed and incorporated into the care plan. The Registered Person must ensure that there is a clear system in place for monitoring and reviewing those residents who self medicate and that this information is clearly stated within the relevant care plans. The Registered person must ensure that the remaining staff complete training in the Protection of Vulnerable Adults. The Registered Person must ensure that action is taken to address the health and safety issues to the exterior the home. (previous requirement). DS0000008454.V297674.R01.S.doc 3. YA20 13(2) 31/12/06 4 YA23 13/18 31/12/06 5. YA24 13/23 31/01/07 Brookfield Residential Care Home Limited Version 5.2 Page 24 6. YA35 18(1) The Registered Person must ensure that all staff complete training in fire safety. (previous requirement). The Registered Person must ensure that monthly reports are undertaken as outlined within the Regulation and copies are forwarded to the CSCI. (previous requirement). 31/01/07 7. YA37 26 31/12/06 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. Refer to Standard YA20 Good Practice Recommendations The Registered Person is advised to ensure that handwritten entries on the MAR sheets are checked, dated and countersigned ensuring information reflects that on the prescription. Tipex must not be used. The Registered Person should explore staff training in relation to the specific health needs of residents. The Registered Person should forward copies of certificates to CSCI evidencing the completion of the Level 4/RMA. 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. 2. 3. 4. YA35 YA37 YA42 Brookfield Residential Care Home Limited DS0000008454.V297674.R01.S.doc Version 5.2 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: 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.V297674.R01.S.doc Version 5.2 Page 26 - 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!