Inspection on 17/07/07 for Brooklands

This inspection was carried out on 17th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brooklands 10/06/08

Brooklands 04/07/06

Brooklands 07/02/06

Brooklands 31/10/05

Brooklands 17/11/04

Brooklands 12/05/04

Brooklands 04/11/02

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Brooklands Wych Cross Forest Row East Sussex RH18 5JN Lead Inspector Gwyneth Bryant Key Unannounced Inspection 08:45 17th July 2007 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 Brooklands DS0000013968.V343231.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. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands Address Wych Cross Forest Row East Sussex RH18 5JN 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) 01825-712005 01825 713090 Mr Hadi Rajabali Mrs Shehnaz Rajabali Mrs Catherine Esther Sheil Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (29) of places Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated at any one time is twenty nine (29) That the care home provides general nursing care to older people aged sixty five (65) years or over on admission and can provide care to people with a physical disability. That one named service user aged 52 years to be accommodated. Date of last inspection 4th July 2006 Brief Description of the Service: Brooklands is registered to provide general nursing care for 29 residents and admits those who are either privately funded or funded by Social Services. The home is situated on the A22 at Wych Cross, approximately three miles south of Forest Row village. It is an old building that has been converted for its current purpose. Building extensions have been tastefully added to keep the atmosphere of the older building. The home comprises of 25 single and 2 double bedrooms. All except two of the rooms have en-suite facilities with additional toilet and bathroom facilities throughout the home. Rooms are located over two floors, accessible by a passenger shaft lift. There are extensive attractive gardens to all sides of the property that are accessible to residents. There are car-parking facilities to the front of the premises. Due to the rural location of the home, there are no local amenities within easy access of the home. No public transport is accessible, except for taxis. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £719 - £820 per week which includes toiletries; additional charges are made for newspapers, hairdressing and chiropody. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit carried out over 6.5 hours by two inspectors and its purpose was to assess the service provided and ensure shortfalls identified at the last inspection had been addressed. Ten people living in the home were spoken with on the day, in addition to the Registered Manager, the cook, two visitors and one carer. A tour of the premises was carried out and a range of documentation viewed including staff recruitment records, care plans and staff training records. Comments from those living in the home included: ‘very happy here – the staff are marvellous’ ‘I have every opportunity to keep in contact with my family and friends’ ‘all very nice – no complaints’ ‘they are all so kind’ ‘the food is very good’. ‘(my) needs are more than met’. Prior to the site visit information was requested from the provider; this was given and information detailed is used in this report as necessary. What the service does well: What has improved since the last inspection? The use of correction fluid on medication administration records has ceased and the policies and procedures on adult protection have been amended in line with the latest good practice guidance. A qualified Occupational Therapist has made an assessment of the home and grounds to ensure the disability needs of individuals are met. The home is on target to ensure at least 50 of care staff have National Vocational Qualification in care at level 2. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 7 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 Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 8 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): 2, 3 and 4. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory pre-admission assessments are carried out prior to people moving into the home, which ensures that their needs can be met, and they are provided with detailed information on services offered by the home. EVIDENCE: Pre-admission documentation was viewed for recent admissions and all care needs are identified and planned for prior to people moving into the home ensuring that needs of prospective residents can be met. The Registered Manager confirmed that people are invited to visit Brooklands prior to moving in and that copies of the service users guide is provided for all individuals as are contracts detailing the terms and conditions of residency. Intermediate care is not provided. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 9 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): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health, social and care of those living in the home are met but improvements need to be made to all aspects of the care recording process to enable all staff to deliver care in a structured and consistent manner. EVIDENCE: Those people spoken with confirmed that they felt their care needs were being met at the home. Individual care plans were not looked at in detail, as there were no shortfalls noted at the last inspection. Documentation regarding specific areas of care needs were viewed. There was evidence that care plans were being reviewed on at least a monthly basis. It was discussed with the Registered Manager on the day of the site visit, that the reviewing process be reassessed, as care plans viewed showed that some staff were using care plans as recording daily notes. This has not been reflected as a requirement or recommendation as the Registered Manager confirmed that she would address this with the staff. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 10 Eight care plans were viewed and it was found that they generally provided an overview of needs of those living in the. home and provided staff with information on how to meet these needs. Some areas of specific nursing needs could be detailed better. There was no care plan or guidance in place for one person who required a wound dressing or for one dressing placed on another individual as a preventative measure. There was clear documentation and recording in place for all other wound dressings undertaken at the home. The Registered Manager confirmed that advice is sought from the tissue viability nurse when the need arises. There are no records maintained for when indwelling catheters are due for a change. This was discussed with the Registered Manager on the day of the site visit who agreed to address the matter with all staff. It was noted that an assessment form used to risk assess if someone is at risk of developing pressure areas provided no information on what the overall scoring means. Care plans for pressure area care did not read as being personalised to the individuals. Not all risk assessment documents were fully completed; therefore not all risks were identified. Overall there was good documentation regarding fluid balance charts and turning charts. These are tools used to record care given for residents who may require full care due to their high level of needs. It was discussed with the Registered Manager the importance of staff recording what pressure relief is provided when an individual is sat out of bed all day and to also record when oral health care is provided. The home admits many residents who have high needs and may be near the end stage of their life. The Registered Manager confirmed that the home liaises closely with the local GP and hospice centre for advice. Staff receive talks on palliative care to ensure they are aware of end of life care needs. There is pressure-relieving equipment available at the home, however an Inspector observed that a pressure mattress was not being used correctly. The Registered Manager addressed this at the time of the site visit and confirmed that she also checked other pressure relieving mattresses in use. It was confirmed that there are a further nine adjustable nursing beds that need to be put in place. The Registered Manager confirmed that the type of bed available is taken into account when admitting people to the home. Medication Administration Records (MAR) charts viewed demonstrated that medication is generally signed for at the time of administration. A nurse was observed to leave medicines with an individual to take later, however still signed the MAR chart. This was addressed with the individual on the day. The home has recently changed the process for receiving medications into the home. This is now done on a weekly basis with the supplying pharmacist. The Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 11 Registered Manager confirmed that this allows medication to monitored more accurately. Some MAR charts showed that a medication had not been signed for, however there were no records available to see if this had been administered or not. No requirement or recommendation has been made in relation to this as the Registered Manager can ascertain from records who was working and address this issue directly with the individual involved. Accurate records are being maintained for controlled drugs, however clear records must be maintained for the use of prescribed creams/ointments. Some MAR charts had prescribed creams on them, however these were not being signed for. A registered nurse confirmed that some creams were used when required or were no longer in use. There was no indication when a cream should be used or information available where the cream is to be applied. It was noted that the home holds a stock of various creams. One prescribed ointment still in use was not being signed for. Prescribed cream was found to be in an individuals’ room for whom it had not been prescribed. An Inspector observed an inhaler being used regularly had expired in April 2007. This was addressed on the day of the site visit, however all nurses must be reminded of the correct checks to make prior to administering medicines. It is recommended as good practice that any handwritten prescriptions are double signed by staff who have received medication training. The Registered Manager confirmed that unused medication is disposed of through a licensed company as required by legislation. It was observed that hygiene care plans are pinned up in individuals’ rooms providing care staff with a quick overview on specific hygiene needs. It was discussed with the Registered Manager that although these provided clear information for the staff, it might not promote the privacy and dignity of the residents. Those people spoken with confirmed that they felt their privacy and dignity are respected. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although meals are well balanced, varied and nutritious, people living in the home also need to have the opportunity to experience a lifestyle that matches their expectations, choice and preferences in respect of daily routines and leisure activities. EVIDENCE: Information provided prior to the site visit indicated that the home strives to offer choice to those living in the home, however limited activities are provided within the home. Improvements need to be made to ensure daily activities are provided, based on the preferences of those living in the home. The Registered Manager said that most people preferred one-to-one activities but one person in the home said they were bored and it was evident a number of others remain in their rooms for long periods of time which may result in social isolation. This was exacerbated on the day as the carpets in the communal lounge and dining room were being cleaned so none living in the home could access these areas. One individual said that they would like to have one-toone chats with staff but this had never been offered. The Registered Manager added that attendance at activities was low but given the high turnover of people living in the home and the lack of regular activities it is not possible to Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 13 substantiate a consistent attempt to offer daily activities. The home does provide visits from a PAT (pets as therapy) dog and communion is also provided monthly in addition to manicures and one-to-one chats with staff. Due to the location of the home visits by individual ministers is difficult but the Registered Manager confirmed she would be happy to find a means of meeting any other religious needs expressed by individuals if required. People spoken with confirmed that, with help from friends and family they are able to access the wider community and visitors are welcome at all times. On the day there were a number of visitors and it was evident they were comfortable approaching both staff and the manager with any queries. Two visitors to the home on the day were there to enquire about vacancies in the home, based on recommendations from a friend demonstrating that the home has a good reputation locally. Meals remain good with those people spoken with confirming that they are offered a choices at each mealtime. A kitchen assistant was seen to be asking people in the home what meal they preferred on the day. The cook was spoken with and it is clear she has a good understanding of nutritional needs in general and of particular dietary needs for those who are diabetic. The daily notes showed that staff are required to record the times when individual refuse a meal but there is no procedure to follow this up with offers of either an alternative or a snack offered later. This was discussed with the Registered Manager who said that this does happen even though it is not recorded but it is good practice to provide a nutritional audit trail for those people whose appetite is poor. Throughout the site visit staff were observed to interact positively with those living in the home and it was evident that they are knowledgeable about individual care needs. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 14 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): 16 and 18. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system with evidence that those living in the home, felt confident their views would be listened to, further protection would be provided to people living in the home if all staff received training in adult protection procedures. EVIDENCE: The home has policies and procedures on complaints and all complaints are recorded and include actions taken and outcomes. One person spoken with said that they knew how to make a complaint and that they would be comfortable doing so. Another individual said they would not know how to make a complaint, however they had never thought about doing so. The home has policies and procedures on adult protection but none of the staff have received up to date training in this matter and this was discussed with the Registered Manager who agreed to address this matter without delay to ensure staff are aware both of what constitutes abuse and action to take in the event of an allegation. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 15 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): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is good, providing a homely, safe and comfortable for those living in the home. EVIDENCE: A tour of the premises was carried out and all parts of the home was clean, tidy and well maintained. People moving into Brooklands are encouraged to bring in possessions to personalise their rooms and many have done so with photographs, furniture and ornaments. Both the rear and front garden areas are attractive and well maintained. It was pleasing to note that bird feeders had been hung outside the window of one persons bedroom allowing them to observe the birds eating and a squirrel which also feeds from the feeders. It was evident that this provides much pleasure to the individual concerned particularly as she is unable to get out of bed. Since the last inspection a qualified Occupational Therapist has made an assessment of the grounds and premises ensuring that aids, adaptations and equipment are provided to promote the independence of people living in the home. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 16 One Inspector noted that there were commodes provided for people whose accommodation included with en suite facilities. The Registered Manager confirmed that these were in place at the request of the individuals concerned and not for the convenience of staff. Although call bells were provided in all room some were not left in reach of individuals who remain in their rooms. Bed rails noted to be in use were covered, however some of the covering in use was noted to be dirty and tatty. The Registered Manager must ensure this is addressed. Bed rail covers were not in place for the new design of adjustable beds in use, as the Registered Manager confirmed that it is the manufacturers guidance that covers are not required for these bed rails. The Registered Manager needs to ensure that consent forms and risk assessments are in place for all people who use bed rails. Laundry facilities are clean and hygienic. Systems are in place for the control of infection and all staff have been trained in this area and were observed to be working in ways that minimised the risk of infection, by wearing gloves and aprons when required. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff with the skills and knowledge to provide consistent care to those living in the home and recruitment practices are robust offering further protection to those people living in the home. EVIDENCE: Staff rotas indicated that there are five staff on duty for each shift in addition to a senior, the Registered Manager, cook and domestic staff. Staffing for each consists of two Registered Nurses and four care staff. The Registered Manager confirmed that staffing levels are regularly reviewed based on the care needs and numbers of people living in the home. Visitors spoken with said: ‘staff are fantastic’. ‘they always have a consistent attitude’. ‘they try to encourage residents to do more’. ‘I am impressed at the improvement in mother since she has been here’. Information provided prior to the site visit indicated that of the twenty-one staff, eight are qualified nurses and of the thirteen care staff four have achieved at least National Vocational Qualification level 2 in care and a further four are working towards this qualification. Therefore the home is on target to meet the required 50 of care staff with this qualification. This document also showed that all staff have been trained in infection control, manual handling, Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 18 fire safety and health and safety. It was confirmed that additional training is provided to registered nurses specific to their roles. There is an induction programme for all staff and the Registered Manager and a senior nurse also provide mentoring for the qualified nurses. Recruitment records for the last two people to be recruited were examined and all had provided proof of identity and two written references in addition to satisfactory Criminal Record Bureau and Protection of Vulnerable Adults First checks. In order to fully comply with the regulations staff need to provide a fully employment history and complete a health declaration and the Registered Manager agreed to address this without delay therefore no requirement or recommendation was made. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from clear leadership and direction and most aspects of their health, safety and welfare are protected and promoted. EVIDENCE: The Registered Manager has the required qualifications and provides good leadership, in an open and approachable manner. Throughout the site visit it was evident that both staff and those visiting the home are happy to approach her with any concerns demonstrating there is a relaxed and welcoming atmosphere. The home does not handle the monies of people living in the home, the Registered Manager notifies the family members if clothing or other items are required. The Registered Manager carries out a number of quality assurance procedures including providing, surveys for both relatives and those living in the home, Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 20 staff training, resident and staff meetings and supervision. These need to be structured and collated to formalise the quality monitoring process to enable the Registered Providers to evaluate all aspects of the service and ensure it is run in the best interests of those living in Brooklands. The Registered Providers also need to visit the home each month and provide a written report, available for inspection, as part of the quality monitoring process. Documents relating to Health and Safety were available and found to be satisfactory as were accident records. There were records showing the regular testing of emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. The staff training programme ensures they are trained manual handling, infection control, fire safety, food hygiene and first aid. A fire safety risk assessment has been carried out on the premises and all the requirements had been addressed, however a number of doors were found to be wedged open including fire door in the corridors. This practice puts both staff and those living in the home at risk in the event of fire. There were a number of wheelchairs throughout the home, some which were in use and none had footplates attached. Transporting people in wheelchairs without footplates puts them at risk of injury and therefore this needs to be addressed. Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 21 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 X 3 3 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X x 2 Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15(1) (2) Requirement That all care plans include detailed information on meeting nursing needs, in particular those relating to wound dressings. That records of the administration of prescribed creams be made and that they are used solely for the service users they are prescribed for. That a planned programme of activities based on service users interests be devised and implemented. That all staff be trained in adult protection. That formal quality monitoring and quality assurance systems be created and implemented. That the Registered Provider make monthly visits to the home and make the subsequent reports available to the CSCI. That fire doors are not wedged open and appropriate self closing devices fitted as required. That all wheelchairs are fitted with footplates. Timescale for action 17/08/07 2 OP9 13 (2) 17/08/07 3 OP12 16 (2mn) 17/09/07 4 5 6 OP18 OP33 OP33 13(3) (6)(8) 24 (1ab) (2)(3) 26 (1) (3) (4) (5) 23(4a) (c)(i) 13 (4)(b)(c) 17/09/07 17/10/07 17/08/07 7 8 OP38 OP38 17/08/07 17/08/07 Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Brooklands DS0000013968.V343231.R01.S.doc Version 5.2 Page 25 - 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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