Inspection on 13/07/05 for Brookfields

This inspection was carried out on 13th July 2005.

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

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

Other inspections for this house

Brookfields 07/03/07

Brookfields 20/12/05

Brookfields 22/03/05

Brookfields 19/10/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Brookfields 81 Dogkennel Lane Oldbury West Midlands B69 9LZ Lead Inspector Patrick Wright Announced 13 July 2005 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 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 Stationary 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. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Brookfields Address 81 Dogkennel Lane Oldbury West Midlands B69 9LZ 0121 544 6715 as above N/A Milbury Care Services Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ruth Bailey Care Home with Nursing 6 Category(ies) of Learning Disability (6) Physical Disability (6) registration, with number of places Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 March 2005 Brief Description of the Service: `Brookfields` is a converted and extended residential building owned by Milbury Care Services. The property is two storey with residents accommodated on the ground floor only, the first floor is used for meetings and office space, and it also provides the laundry area and staff toilet. The home provides a nursing service for up to 6 persons with a learning and physical disability. Aids and adaptations are provided which meet the assessed needs of the service users. The home is located in a quiet residential area of Oldbury, with local shops-amenities a short distance away. There is limited off road parking to the front of the house with a large spacious garden to the rear.Each of the rooms is single occupancy, and a communal lounge, dining kitchen and activity area are available. The home does not offer en-suite facilities. Overall the home is decorated and maintained to a high standard. Service users are enabled to participate in a wide range of `in –house` and community based social and recreational pursuits, plus a helathcare programme, which utilises various healthcare resources within the local area. Transport is available through the homes own adapted vehicle. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over 6 hours, and was a statutory announced inspection of which the home had approximately six to eight weeks notice. The purpose of the inspection was to assess progress and compliance in meeting the National Minimum Standards and towards addressing items identified at previous inspection visits. A range of inspection methods was used to make judgements and obtain evidence, which included discussion with the Registered Manager, Deputy Manager and interviews with two staff, (one of the qualified nurses and a support worker). There was also a tour of the premises, and rear garden. There are six residents currently living at Brookfields. The home is registered to provide nursing care for adults with learning and physical disabilities, and other complex needs. One of the residents was able to comment on the care he receives and offered positive feedback about the home and care staff. All of the residents were present during the inspection, but formal interviews were not appropriate. Therefore the inspector relied upon body language, known responses and other observations of interaction between staff and residents. A number of records and documents were also examined. Other information was gathered prior to the inspection, which included the pre-inspection questionnaire and feedback from relatives. Residents who were observed/spoken with during the inspection appeared comfortable with the quality of care provided. Brookfields nursing home utilise specialist/clinical services as required. The service recognises good practice and accesses the British Institute of Learning Disabilities, and others for guidance. At the time of the inspection, the home had the capacity to demonstrate it was meeting residents assessed needs and this was more than evident through discussion with the manager and staff, observations made, and reviewing documentation. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? The manager and staff have responded positively and enthusiastically to advice given about considering ways of implementing a person centred planning approach. Each of the residents are in receipt of a `Lifestory book`, produced with their keyworker and includes pictures, photos, symbols, and colours. This piece of work has been completed with the residents, and staff have also contributed to their own `Lifestory books` to help them understand the value of the exercise. The management of the home are now looking to the next stage of the process, and hope to achieve this at the same time as the residents annual reviews are held. Residents have greater access to the homes transport and reimbursements have been made for periods of time that the vehicle could not be used due to the lack of a driver at the home. Suitable laundry equipment (which includes a sluicing facility) may have been identified which can be installed in the current laundry room. It was previously stated this was not an option as the laundry is located on the first floor and the weight of the equipment was thought to be excessive for the flooring, hence one of the reasons for requiring the laundry to be relocated to the ground floor. However, this may not be necessary if the equipment can be safely installed and effectively used for a trial period, whilst on loan from the supplier. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 7 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. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 The homes Statement of Purpose and Service User Guide provides service users and prospective service users with details of the services the home provides, enabling them to make an informed decision about admission. The admission process includes a proper assessment prior to moving in to the home, to ensure the individuals care needs can be met. EVIDENCE: The home has a Statement of Purpose and Service User Guide, referenced to Standard 1 of the National Minimum Standards for Younger Adults and Regulation 4/5 of the Care Homes Regulations 2001. Copies of both documents have been submitted to the Commission for Social Care Inspection. The range of fees charged to service users is available in the individuals `Service Agreement` The Service User Guide has been issued to the residents, and includes pictures or symbols. Service users files have records detailing attempts made to vocalise the content of the document with the individual. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 10 The home has been fully occupied since the last inspection and has therefore not admitted any service users. The manager of the home is aware that prospective service users should be admitted only on the basis of a full assessment with supporting Care Management documentation. Existing service users assessments are being regularly reviewed and the home continues to use the `Everyday Living Skills assessment/inventory` as a baseline tool. Service user files evidenced that staff are reviewing different parts of the needs assessments on a regular basis throughout the year. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 11 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 standard(s) 6,7,and 9 There is a clear and consistent care planning system in place which includes regular evaluation. Service users are encouraged to contribute and are given assistance where help is needed and the system is subject to a rigorous risk assessment process. EVIDENCE: A sample of care plans was examined and all were found to be appropriately maintained. Each resident is in receipt of a care plan which varied in content dependent upon the needs of the service users. The care plans detailed various areas of need including physical, social, and psychological elements (The home utilises external General Nursing colleagues through referral, as needed). Monthly evaluations are taking place, and with the involvement of the service users key worker. The key worker team /named nurse system is well established and responsibilities covered a range of issues. The sample of plans seen, set out the action which needs to be taken by care staff and accurately reflected the individuals’ everyday needs. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 12 An overview of the documentation seen suggested staff respect the service users’ right to make decisions. This was confirmed through interviewing two of the staff team. This was evidenced through records of participation in leisure/recreational pursuits, activities of daily living and positive forms of communication between service users and staff. Documentation reviewed and staff interviewed confirmed that staff can demonstrate/justify why decisions are made on service users behalf and how. Residents were identified as being unable to manage their own financial affairs without support. The home has a risk assessment process which identifies potential risks and risk management strategies. The risk assessment form identifies who is at risk, the level of risk, existing control measures and any other control measures required, as well as the actual date of review. The home uses a risk assessment system with interventions and guidelines for staff clearly described. Staff interviewed had an understanding of the risk management framework within the home. Individual risk assessments are found in each of the residents files. residents are fully risk assessed in a variety of activities and topics. All Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 13 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 standard(s) 16 and 17 Services users rights are respected, and daily routines are modelled around the individuals. The meals in this home are good, with evidence that service users are offered quality meals and choice. EVIDENCE: Residents are offered a choice of meals from a seasonal menu prepared, and based on their preferences. Through discussion with staff they were able to show they had a good understanding of what the service users likes and dislikes were and respected this. Meals, snacks, drinks are offered regularly and service users generally tend to eat together in the dining area, not only because personal assistance with feeding is required for some people, but because mealtimes are seen as a social time with staff sitting and eating with service users. Meal times are relaxed and unhurried and service users requiring assistance are provided with such in a dignified manner. Residents who require a soft diet or blended meal are offered the same menu choices, and the meals presented appropriately. Service users nutritional needs are routinely assessed regularly and personal weight monitored. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 14 Observations and discussions with staff, management and residents identified that routines are flexible to suit the needs of individuals. This was supported by evidence in personal notes, daily activities and care plans. Some housekeeping tasks are undertaken with service users present, for example, cooking and making drinks. One of the service users was helping prepare lunch in the kitchen, and asked the inspector to join the group for lunch. The meal was sweet and sour chicken with pasta and was well prepared and presented. The service user said “ I like it in the kitchen, I cooked the dinner” Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 15 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 standard(s) 18 and 20 Personal support is offered in such a way as to promote and protect the service users preference and in a way that meets their needs. The systems for the administration of medication are good and arrangements are in place to ensure service users medication needs are met. EVIDENCE: Through records, observations and discussions with staff, it was identified that personal support is provided which ensures that principles of privacy, dignity and independence are adhered to. Service users can get up/go to bed when they choose, withdraw to their room for privacy and choose their own clothing, amongst other issues noted. Staff interviewed are aware of these principles and also of the need for confidentiality. A service user stated “the staff looked after me properly”. The home operates a named nurse/key worker system with individual responsibilities documented. Registered Nurses (Learning Disability and General trained) provide nursing care within the home. All care is recorded, monitored and evaluated /reviewed. The home operates a monitored dosage system (MDS) and records are kept of all medicines received, administered and leaving the home. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 16 A visiting pharmacist for the MDS regularly visits the home for the purpose of audit, and to advise on the homes implementation of the system. The home should purchase a medication fridge and temperature gauge to replace the domestic kitchen fridge currently used. This being due to its age and the implications of monitoring its internal temperature. The Manager was also told that from April 1st 2005 a new NHS contract for community pharmacists was introduced. Effective immediately, care homes (nursing) are prevented by law from returning waste medicines to a community pharmacist. Arrangements must be made with a licensed waste management company, as required for other clinical waste. Therefore community pharmacists cannot accept medication waste from care homes (nursing only), unless their pharmacy holds a Waste Management Licence. This must be explored with the community pharmacist and records be maintained of the system in place, for the purpose of inspection. None of the service users at Brookfields self medicate and it is unlikely, due to the nature of disability, to be able to secure consent to medication being given. The manager has written a statement to this effect detailing the responsibilities of the home to the service users and consent/agreement obtained where possible with the individuals relatives/representatives being involved. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 17 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 standard(s) 23 Arrangements for protecting service users from abuse and providing a safe environment are satisfactory. However, some anomalies in handling service users personal monies have been identified. Staff have appropriate knowledge and an understanding of adult protection issues. EVIDENCE: The home has an Adult Protection policy which is referenced to Department of Health (DOH) guidance ‘No Secrets`. This policy has been brought to the attention of all staff, through a staff meeting and briefing session. This was evidenced by obtaining the signatures of staff that attended. Training in Adult Protection issues has been provided for the majority of staff, and certificated evidence was available but the manager said it was sometimes difficult getting the certificates from the organisations training department. The home has copies of the Department of Health (DOH) guidance ‘No Secrets`, and the local Sandwell Vulnerable Adults Procedure. Residents were identified as being unable to manage their own financial affairs without support. Some elements of practice within the home need to be reviewed against Millbury’s policies and in consultation with the relevant contracting department. For example, records of expenditure identified service users were on occasions, paying for staff costs to escort them on outings (for bus tickets and for drinks). Service users monies must not be pooled together on trips/activities, utilised for the purpose of purchasing food which is provided as part of the fee/charges or used for paying for staff meals, drinks etc, when accompanying the service users into the community. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 18 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 standard(s) 24 and 30 The standard of the environment within this home is good providing service users with an attractive and homely place to live. Infection control measures are in place but can be improved with the installation of new laundry equipment, and upgrading of the facilities. EVIDENCE: The environment at Brookfields is very pleasant and the premises continue to be maintained to a good standard. The homes furniture and fittings, are domestic in style, homely and comfortable. Service users rooms have benefited from individual redecoration, and replacement carpets. The staff employed at the home redecorate the rooms rather than `buy in` outside services, and they have done an excellent job in demonstrating/maintaining the individuality and preferences of the occupants and capturing their personalities. One service users room still requires redecoration and the carpet needs replacing (J.B). This is not through a request or the choice of the occupant but due to extensive wear and tear, and must therefore be funded by `Milbury`. Discussion took place with the Service Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 19 Manager and Registered Manager about the providers routine redecoration plan, and how this must be implemented regardless of whether individuals may choose to have their rooms redecorated in between the schedule. Evidence of choices and preferences of when this occurs must be available. The home is not accessible in all parts to residents. The first floor provides a training room, office, and laundry area, which existing service users cannot access. A passenger lift is not provided. The rear garden area was noticed to be in need of attention and the area previously identified for possible development should be attended to. The external space would benefit from additional patio space. The organisation should not expect the staff team to maintain the garden in addition to providing a nursing service to this group of vulnerable adults. A tour of the communal areas took place and the home was found to be very clean, tidy and free from any offensive odour. There are laundry facilities available which are kept separate in a room designated for the purpose. Equipment currently provided ensures laundry is washed at appropriate temperatures, but does not offer the appropriate sluicing facilities. The facilities are used on a daily basis, but as stated, in terms of service user access, laundry facilities are not ideally situated. Discussion took place with the Manager about the issues surrounding the laundry area being on the first floor, and the progress made with regard to relocating the service area. The Manager told the inspector that suitable laundry equipment (which includes a sluicing facility) may have been identified which can be installed in the current laundry room. It was previously stated this was not an option as the laundry is located on the first floor and the weight of the equipment was thought to be excessive for the flooring, hence one of the reasons for requiring the laundry to be relocated to the ground floor. However, this may not be necessary if the equipment can be safely installed and effectively used for a trial period, whilst on loan from the supplier. If this course of action is adopted the current area requires updating to include a separate handwashing sink and wall/floor finishes which are impermeable and washable. Equipment stored in the room should be removed and all items which may be hazardous to health, stored appropriately. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) nil No standards from this section were assessed as part of this inspection EVIDENCE: Not applicable Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home regularly reviews aspects of its performance through a good programme of self review and consultations, which include seeking the views of service users, relatives and staff. The manager is seen to ensure as far as reasonably practicable the health, safety and welfare of service users and staff. EVIDENCE: Brookfields retained its Investors in People award in March 2005, and has previously won a small business award, with the Milbury organisation. The nursing staff at the home continue to undertake ‘quality checks’ within the home and a series of meetings are used to measure and discuss relevant issues. Individual staff performance is monitored through `one to one` supervision sessions. Questionnaires remain available for service users/their families/representatives and visitors. Comment cards received from relatives of service users with regards to this inspection all provided positive feedback about the quality and standard of the service delivered at Brookfields. Comments include “ I think it is a good home” and “ We are very happy with Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 22 the care given to our relative…it is a great relief to know he is looked after in this way, thanks to everyone”. Visits to the home by a Milbury Service Manager are being conducted monthly as part of the organisations audit system and to meet the Care Home Regulations 2002. The home also reviews its aims and objectives annually which qualify as part of the services annual development plan. Reviews of care plans are held monthly and activities regularly evaluated to monitor the outcomes for service users. Brookfields staff team continue to show a good awareness regarding safe working practices. A random sample of maintenance and service records were examined, and were all found to be available current and maintained as required by legislation. The standards were good. Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x x x x 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brookfields Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 6 Regulation 15 Requirement The home should implement a system of Person Centred Planning / Essential Lifestyle Planning The manager must ensure that a) the homes chosen community pharmacist holds a Waste Management Licence for the disposal of unused medications or alternative arrangements are made with a Waste Management company. b) The home should purchase a medication fridge and temperature gauge to replace the domestic kitchen fridge currently used. The practice of Service Users paying for staff to escort them on outings, for bus tickets and for drinks etc must cease. Service users monies must not be pooled together on trips/activities, utilised for the purpose of purchasing food which is provided as part of the fee/charges or used for paying for staff meals, drinks etc, when accompanying the service users into the community. The service users room requiring DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Timescale for action March 2006 August 2005 2. 20 13 3. 23 13 July 2005 4. 24 23 September Page 25 Brookfields Version 1.40 5. 30 13, 23 redecoration and replacement carpet, and the rear garden needing attention must be addressed Proposals including estimated timescales, for the installation of replacement laundry equipment, including a sluicing facility and upgrade of the area, (or the relocation of the laundry room) should be submitted to the Commission for Social Care Inspection. 2005 October 2005 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 37 Good Practice Recommendations That the manager achieves a level 4 NVQ or equivalent by the end of 2005 Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill, Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brookfields DE55 S4823 Brookfields V232090 13-07-05 Announced Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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