Inspection on 06/02/07 for Brookfields

This inspection was carried out on 6th February 2007.

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 19/03/09

Brookfields 05/12/05

Brookfields 08/07/05

Brookfields 12/01/05

Brookfields 12/07/04

Brookfields 05/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Brookfields 488 Burton Road Derby DE23 6AL Lead Inspector Steve Smith Key Unannounced Inspection 6th February 2007 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookfields Address 488 Burton Road Derby DE23 6AL 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) 01332 343840 01332 294558 Brookfields P.N.H. Limited Susan Buxton Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (5) of places Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Brookfields is a detached house, which has been adapted and considerably extended to become a nursing home for Older People. The Registered Company is Brookfields Private Nursing Home Ltd. It is situated in Littleover, just a short way from local shops and a bus route. The Home provides nursing and personal care for up to 34 persons aged 65 years and over with physical health needs, and facilities are provided across two floors. The Home provides 26 single and 4 double bedrooms, with 29 rooms having ensuite facilities. Access to the first floor is by stairs or by one of the two passenger lifts. The Home has a dining room and 2 lounges on the ground floor. The garden is accessible to all Residents. The charges made for a room at Brookfield Nursing Home range from £477.00 to £560.00 a week. These charges are dependent on the size of room, the facilities provided and whether the Resident is sponsored by a Social Services Dept or is privately funded. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in just over 7.25 hours. Discussion was held with two Residents, and the records of four Residents were ‘case tracked’. Discussion was also held with one of the Registered Providers, the Manager of the Home and with two care staff. A number of records were examined, and a number of the Residents bedrooms and all public areas of the Home were examined. The Commission’s pre-inspection questionnaire, sent to the Manager, was examined. The Commission’s questionnaire was sent to a selection of Residents, and five were returned at the time of this inspection. All spoke most highly of the Home. What the service does well: The issues mentioned in these next three sections of the report were the items inspected on this visit to the Home. The Registered Providers and Manager had ensured that a statement of purpose and Residents Guide were in place, although some updates were required, and all new Residents moving to the Home were appropriately assessed. Good records of care were maintained, as were the health care needs of the Residents, although again some improvements were needed. Medication issues were well met in the Home, but one minor improvement was required. Two Residents were interviewed during this inspection, and they were most complimentary of staff, saying that their care needs were always well met. The Manager provided a good complaints procedure, and ensured that a good Safe Guarding Adults procedure operated within the Home. The Home was also maintained to a very good physical standard throughout. An excellent level of staffing was provided within the Home, so Residents were cared for appropriately. The Registered Providers had ensured that good numbers of staff had acquired at least NVQ level 2 in Care. New staff to the Home were also appropriately recruited. The Manager was appropriately qualified and the Home was regularly ‘inspected’ by the Registered Providers. Some Quality Assurance issues were met, although again some improvements were needed. All Residents had been provided with a risk assessment to help in determining their safety. All accidents, injuries and incidents of illness or communicable Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 6 diseases were recorded and reported to the relevant government bodies. The Registered Providers had also ensured that fire safety notices were posted in relevant places around the Home. What has improved since the last inspection? What they could do better: The Registered Providers need to update the statement of purpose and Residents Guide to ensure it covered the physical environment standards, and all of the new requirements, dated from September 2006. Residents care plans needed attention to ensure that all necessary information was recorded, and acted upon. The Manager needs to ensure that the deteriorating needs of Residents suffering with dementia conditions were appropriately recorded within Residents plans of care. When a Doctor changes a Resident’s medication, staff need to record on the Medication Administration Record sheets the name of the Doctor authorising the change, including the date this was to occur. The Manager needed to offer Residents the opportunity to plan their funeral arrangements shortly after moving to the Home. She also needed to ensure that staff knew which bedrooms they needed to await an answer following their knocking on the bedroom door, and which rooms they needed to knock and enter, because of the differing conditions of the Residents. The Registered Provider needed to ensure that a choice of meal was available at all meals offered to Residents in the Home. The Manager was encouraged to begin to record verbal complaints within the Complaints File along with written complaints, instead of only within Residents plans of care. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 7 Staff call lines needed to be provided within easy reach of Residents using the bath and toilet in the Home’s bathrooms. The Registered Providers Quality Assurance issues were only partially addressed, and they needed much more regularly added detail to be satisfactory. Care staff still needed to receive regular supervision. This has been outstanding since 2004. Staff were behind schedule with their training on First Aid, Food Hygiene and Infection Control. Lastly, the Manager was encouraged to provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. 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. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Registered Providers’ statement of purpose and Residents Guide required updating, to ensure that prospective residents would be adequately informed of the operation of the Home prior to deciding to move there. All new Residents moving to the Home were appropriately assessed prior to their admission, so that they were reassured that their needs would be met. EVIDENCE: The Registered Providers had provided a very detailed statement of purpose for the Home together with a Resident’s Guide. However, neither document clearly set out the physical environment standards met by the Home. The Residents Guide was well completed and contained information on how contact could be made with the Commission, the local Social Services Dept and the Health Authority. However, it did not include the considerable amount of information that was introduced during September 2006. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 10 Copies of the Residents Guide were found in each of the Residents bedrooms interviewed as part of this inspection. All Residents had been provided with copies of the statement of terms and conditions of residency in the Home or a contract if purchasing their care privately. Residents were able to say that they had met the Manager, prior to moving to the Home, at the time of the Manager’s assessment of them to determine their suitability to enter the Home. When new Residents were admitted to the Home, the Manager was provided with a summary of the needs of each person, completed by the Social Services Dept Care Manager supporting each Resident. If the Resident was self-funding from the outset, the Manager completed her own summary of needs, which were seen during the inspection. As a result of these two assessments, Residents’ needs would be appropriately met in the home. Standard 6 does not apply to this Home. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents’ health and personal care needs were being met, as demonstrated within care plans. Medication procedures were safely carried out to ensure Residents health care needs were always met. EVIDENCE: To help assess Standard 7, the Resident’s Plan of Care, the records of four Residents were examined, for the purpose of case tracking. Almost all of the basic information, concerning each Resident, was found to be in the files examined. However, the preferred name of the Resident was not recorded within three of the four file. No record was found of the Social Services Dept Care Manager involved in planning the care of one of the Residents. All of the files also lacked the name of the Keyworker allocated to each Resident. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 12 A record of the Manager’s initial assessment of needs of each Resident was maintained. The files also contained a good copy of the care plan and risk assessment. The Manager had not ensured that Residents’ possible limitations of choice, freedom and decision-making abilities, if they were suffering from dementia, were formally recorded or reviewed at regular intervals. The files showed that good records of events affecting each Resident were kept by the Home. However, there was no evidence of the formal reviews of care completed by staff from the Home. The Commission recommends that these reviews should be carried out on at least a six monthly basis, and should be signed by each Resident, where they are able. However, where Residents were judged unable to sign their records, the Manager needed to decide with relatives which relative should act as the Resident’s ‘representative’ and to sign the record as such. Residents’ records were relatively easy to read, with regular entries being made. However, in one file ‘Please Observe’ was written within the Resident’s record, but other staff had not noted the results of their ‘observation’ of the concern. The files were well organised, with different sections, and they were securely stored. However, there was no evidence to show that the Manager reviewed the files on a regular basis, and none of the files contained a confidential section. Staff were observed providing the midday meal for Residents, which was carried out appropriately, almost at all times. However, at one point a Doctor entered the Home needing to speak to a Sister. The Sister, who was feeding a Resident, ended her task without reference to the Resident at all, asked another member of staff to continue assisting the Resident and left the room. The new member of staff took up her task, but again did not speak the Resident at all. This was judged to be very poor practice. Other than this one incident, the care offered to Residents was carried out in a polite manner at all times. Very positive conversation was heard continuing between staff and Residents. Staff were appropriately maintaining the records of Residents health needs. All medication and the method of distributing it to Residents were examined. A good system was found to be in use, although the following one issue required attention: The Medication Administration Record (MAR) sheets contained a number of handwritten entries completed by staff from the Home. These Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 13 additional medications were always signed by two staff, to confirm the correct entry had been made. However, they did not state the Doctor who authorised the medication, or the date on which the new medication was to start. Two Residents were spoken to about life in the Home. They both said that staff were very good at listening to their views on how they liked to be cared for and staff would carry out their wishes. One Resident said that staff always listened to her views and were ‘…very helpful indeed.’ The other Resident said that - ‘staff were ok’. However, both Residents said that their care needs were always met with dignity and respect. As a result, they felt very safe in the Home, and appeared to have a strong sense and appearance of well being. The two Residents were asked about their wishes following their death at the Home. Both Residents said that they didn’t think that anyone from the Home had discussed this with them. A relative was also asked about this, and the relative also said that this had not been raised by any member of staff. This was then raised with the Manager and Registered Provider and both confirmed that it was not the policy of the Home to discuss this with Residents, unless their death seemed likely in the near future. However, one Residents said ‘I think they ought to discuss this with us shortly after we move to the Home.’ Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Residents preferred lifestyles were respected by the Home, and Residents were given a wholesome and appealing diet in pleasant surroundings that enhanced Residents well being. EVIDENCE: Two of the Residents were asked about the activities provided in the Home. Both said that they chose not to join the activities provided. One Resident and her husband said that one Activities Coordinator had recently left the Home, but that the Manager had provided another Coordinator, which was later confirmed by the Manager. However, the Residents were aware of the activities provided, and a list of activities was seen posted on a notice board on a table near to the entrance to the Home. Both Residents said that they decided when they got up and went to bed – ‘I decide when I get up and go to bed, although staff help me into my dressing gown, and I stay in my bedroom and decide when I actually go to bed.’ ‘The staff have been told of my times of getting up and going to bed’. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 15 One Resident said that she went out, with her husband, for meals at restaurants, or to friends houses. Both Residents said that a minister came to the Home once a month and provided services. Both Residents also said that they had a postal vote and so were able to take part in elections, both nationally and locally. Relatives and friends of Residents were able to visit at any time, and could always be seen in private - ‘Yes, I can see my guests in my bedroom’. ‘Yes, my husband can visit daily and I see him in my bedroom, as you can see’. Both Residents, and the relative of one Resident, said that when staff came to the door to their bedroom they knocked, paused and opened the door. One Resident said that she did say ‘come in’, but staff were usually on their way in by the time she had said it. The pattern of knocking and opening the door was followed by the Manager, when the Inspector was being introduced to Residents in their bedrooms. Residents said that their mail was always delivered unopened, and that the Home was a ‘non-smoking’ home, with a separate room for those who wished to smoke. The Registered Provider and Manager said that a choice was always offered at all meals provided by the Home. Both Residents said that a choice was always available at breakfast time, but at dinner time and teatime they were less confident about there always being a choice. Both said that sometimes their was a choice, but not always. The Registered Provider and Manager were encouraged to review this. However, one of the Residents that replied on the Service Users (Residents) Comment cards, said that a good thing about the Home was that one could say, quite informally, that you do not like a meal, and it is usually sorted out informally and amicably right away. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. Complaints and concerns made to the Registered Providers or Manager were addressed to meet Residents needs. The protection policies and procedures provided meant that Residents were well protected. EVIDENCE: One of the Residents said that if they had a complaint to make they ‘would tell the Manager’. This Resident also said that they had complained to the Manager about particular staff actions, and that later the staff had apologised to her. The other Resident said that if she had a complaint she would tell one of the members of staff on duty. However, this Resident had not had to do this. The Commission had not received any notice of complaint since the last inspection of the Home in December 2005. The Registered Provider kept a record of complaints made in writing in the Complaints File in the office. However, verbal complaints were not recorded in the Complaints File. The Manager explained that these complaints or concerns were recorded in Residents personal files. The Registered Providers had a Safeguarding Adults procedure that included a ‘Whistle Blowing’ policy. It was confirmed that all allegations and incidents of abuse would be promptly followed up and that all actions taken would be Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 17 recorded. The policies and practices laid down by the Registered Provider ensured that all staff understood physical and verbal aggression by Residents. The Manager also said that a policy was available to staff stating that they could not benefit from Residents wills. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23, 24, 25 & 26. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Home was well maintained throughout, providing all Residents with a safe, comfortable environment in which to live. EVIDENCE: A tour was made of the Home, which included a sample of the bedrooms of the Residents. The Home was attractively decorated throughout, and the lounges and dining room were very pleasant to sit in, and were provided with the appropriate items for the Residents. The Home’s corridors were very wide, with many pictures displayed along the length of each corridor. The bedrooms seen provided excellent space and provision for each Resident. The garden were also well laid out and looked most welcoming, providing a pleasant view over the busy road that ran by the Home. The Registered Provider had provided appropriate furnishings in all locations seen during the inspection. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 19 Toilets were easily available to all Residents, were clearly marked, and were provided with grab rails where necessary. A call system was available throughout the Home. All bedroom doors were provided with locks on the doors, which Residents could chose to use. All radiators were appropriately guarded, and could be controlled within each bedroom. The Home had appropriate sluicing facilities, and laundry was washed at appropriate temperatures. However, one item was seen to need addressing within the Home: In the bathroom opposite Room 20, no staff call line was found to hang near to the bath. A call line was available, but it hung by the toilet in the bathroom. Although the majority of Residents required assistance in the bathroom, the lack of an available staff call line did not encourage Residents to be alone in the bath, when this was judged to be appropriate. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. The quality in this outcome area was Excellent. This judgement was made using available evidence including a visit to this service. Care staffing was provided to meet the needs of Residents. The Manager always followed appropriate recruitment practices, when employing new members of staff, to safeguard Residents welfare. EVIDENCE: Staffing provided in the Home was compared with that suggested by the Residential Forum. Care staffing provision was found to exceed the minimum recommended by the Residential Forum for 35 Residents at the High Dependency level. The Registered Providers were complimented on the level of staffing provided. These figures were calculated without the Manager’s working time included, as recommended by the Residential Forum. At the time of this inspection it was found that considerably more than 50 of care staff had a qualification of at least NVQ level 2 in Care, and therefore surpassed the expectation of the Commission. The records of two new staff employed during the past 18 months were examined to see whether the Manager had obtained all relevant information about them, and it was found that all information had been obtained. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 21 Staff induction and foundation training was provided for all new staff that came to work in the Home. The Manager also said that all care staff were provided with at least three paid days training a year. Records of all of this training were seen. All staff also had an individual training and development assessment and profile. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 & 38. The quality in this outcome area was Good. This judgement was made using available evidence including a visit to this service. The Registered Providers needed to complete the Quality Assurance programme to assure Residents the Home was run in their best interest. Residents were not being supported by a staff team who were fully trained to meet their needs. EVIDENCE: The Manager was appropriately qualified to manage the Home, having an NVQ level 4 qualification in Management and a Nursing qualification. The records of the monthly ‘inspections’ of the Home, carried out by a Registered Provider, were examined and found to be in good order. The Manager was able to provide an annual development plan for the Home that reflected the aims and outcomes for Residents. She also stated that she Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 23 and her staff would be able to demonstrate the Home’s commitment to lifelong learning and development of each Resident in the Home, which was confirmed during the interviewing of care staff. However, surveys had not been undertaken of Residents opinions of the operation of the Home, and nor were the views of Residents families or friends obtained or of professionals, such as GPs, District Nurses etc on the operation of the Home. The Manager stated that the Home does not hold any savings money for Residents. Residents purchases and hairdressing etc were paid by the Home and relatives were then billed for these amounts. At the previous inspection of December 2005, the Manager was required to commence the regular supervision of all care staff, to be undertaken at least six times a year. The interviews conducted with care staff showed that this was not occurring. The Manager said that she had started regular supervision, but had not, a yet, included all of the care staff. The training required by the Regulations was examined. This showed that Moving and Handling training and Fire training were up to date. However, First Aid training, Food Hygiene training and Infection Control training was needed by some of the staff to maintain good standards within the Home. The Registered Provider ensured that at least one qualified First Aider was on duty on every shift in the home, both day and night. All Residents had been risk assessed to determine their vulnerability and measures had been put in place to provide protection where necessary. The Registered Providers had complied with all necessary legislation, such as the Health and Safety at Work Act 1974, and the Manual Handling legislation of 1992. The Manager was able to show that she had provided risk assessments on the working conditions of staff; that is for care staff, catering staff and domestic staff, but had not provided a written statement of the policy, organisation and arrangements for maintaining these safe working practices in the Home. The Manager was also able to show that all accidents, injuries and incidents of illness or communicable disease were recorded and reported to the relevant government bodies. With the assistance of the Fire Service, fire safety notices were also posted in relevant places around the Home. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5 Requirement The Residents Guide must include the details listed within the legal amendment introduced during September 2006. Each Resident suffering with dementia, or their representative, must have the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Resident’s records, at least on a 6 monthly basis. Staff must respect the dignity of Residents at all times. When staff have to end a task with a Resident, they must always explain their actions to the Resident. If a Doctor requires an alteration or an additional medication to be provided for a Resident, the Medication Administration Record sheet must always be signed by two staff (as it is), dated and state the name of the Doctor DS0000002113.V328913.R01.S.doc Timescale for action 03/04/07 2. OP7 17 Sch 3 No 3(q) 03/04/07 12 3 OP9 13 03/04/07 Brookfields Version 5.2 Page 26 authorising the change to the medication. 4. OP22 23 Staff call lines must be provided within easy reach of Residents using the bath and toilet in the Home’s bathrooms. The Registered Providers and Manager must ensure that they are satisfying all of the Quality Assurance items listed in Regulation 24 and Standard 33.1 to 33.7. The Manager must establish formal supervision for all staff. (This issue should have been addressed from the inspection report dated 31 October 2004) Training must be provided for all necessary staff in First Aid, Food Hygiene and Infection Control. 03/04/07 5. OP33 24 (as amended in 2006) 30/04/07 6. OP36 18 03/04/07 7. OP38 13 & 18 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Refer to Standard OP1 No. 1. Good Practice Recommendations The statement of purpose should clearly set out the physical environment standards met by the Home in relation to Standards 20.4, 21.4, 22.1 and 22.5. This information should then be summarised and added to the Residents Guide. The preferred name of each Resident should be recorded within each file maintained by the Home. A formal record should be maintained of the Social 2. OP7 Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 27 Services Dept Care Manager’s name when the Social Services Dept have sponsored a Resident’s stay at the Home. Residents files should also include the name of the Home’s keyworker allocated to each Resident. The Manager should formally review each Resident’s care plan and risk assessment at 6 monthly intervals. The formal review should include the Resident, their representative and their other involved relatives, the Manager and other involved staff. When staff use the Resident’s record of events to ask other staff to carry out tasks, for example to ‘Please Observe’, the task should be addressed on each entry following until the staff member requesting the task signs it off as no longer needed. After reviewing each Resident’s file, the Manager is encouraged to sign the record. It is suggested that this could be done in a green or red pen, to assist in determining the frequency of these reviews. All Residents files should contain a ‘confidential’ section. 3. OP11 All Residents should be provided with an opportunity to plan their funeral arrangements shortly after moving to the Home. Staff should be made aware of those Residents who should be encouraged, following staff knocking on their bedroom door, to invite staff into their bedrooms and those Residents who can no longer do this. The Registered Provider and Manager should ensure that a choice of at least two meals is available at both the dinnertime and teatime meals. The Manager should keep a record of all verbal, as well as written complaints, in the Complaints File, showing the nature of the complaint and what the Manager or Registered Provider has done about the complaint. Care staff should receive formal supervision six times a year. (This issue should have been addressed from the inspection report dated 31 October 2004) DS0000002113.V328913.R01.S.doc Version 5.2 Page 28 4. OP12 5. OP15 6. OP16 7. OP36 Brookfields 8. OP38 The Manager should provide a written statement of the policy, organisation and arrangements for maintaining safe working practices in the Home. Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Brookfields DS0000002113.V328913.R01.S.doc Version 5.2 Page 30 - 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. 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