Inspection on 24/10/06 for Brooklands 2

This inspection was carried out on 24th October 2006.

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

The inspector 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 2 10/10/07

Brooklands 2 11/04/07

Brooklands 2 03/11/05

Brooklands 2 20/07/05

Brooklands 2 17/03/05

Brooklands 2 06/10/04

Similar services:

Flint House

Hillview Farm

St Vincents

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

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

CARE HOMES FOR OLDER PEOPLE Brooklands 2 11 Old Parr Road Banbury Oxon OX16 5HT Lead Inspector Kate Harrison Unannounced Inspection 24th October 2006 09:00 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 2 DS0000046642.V317158.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 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands 2 Address 11 Old Parr Road Banbury Oxon OX16 5HT 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) 01295 262083 01295 278404 mail@brooklandsnh.co.uk Brooklands 2 Ltd Mrs Doolyn Lacey Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary increase in registration. Temporary increase in registration from 32 to 36 beds for a period of six months commencing 05 June 2006 to provide accommodation for residents who need an alternative location during the first phase of the expansion project at Brooklands 1. Any extension to this period must be discussed with the Commission. 3rd November 2005 Date of last inspection Brief Description of the Service: Brooklands 2 is a three storey late Victorian town house situated in a residential road within easy access of Banbury town centre. The proprietors Mark and Madeleine Taylor also own Brooklands 1, another nursing home nearby, and during the current expansion of Brooklands 1 the Commission has agreed that some residents from Brooklands 1 can be temporarily accommodated at Brooklands 2. The accommodation at Brooklands 2 is spread over three floors served by a passenger lift. The home has temporarily adjusted the accommodation from 17 single rooms and 6 double rooms to 18 single rooms and 9 double rooms; two of the new double rooms were previously lounges. There is an assisted bathroom on each floor, and a small enclosed garden and patio area at the rear of the building. As a temporary measure to accommodate the residents transferred from Brooklands 1, three temporary rooms are in use as lounges and a dining room with covered ramped access from the main house. The weekly fees range from £627 to £721. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The registered manager was not in the home during the visit, and one of the proprietors and the nurse in charge of the home were available. The inspector arrived at the service at 09.00 hours and was in the home for 9.5 hours. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s proprietors, and any information that CSCI has received about the home since the last inspection. The inspector saw all areas of the home, spoke with residents and looked at records and documents relating to the care of the residents. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. 7 residents and 18 relatives replied, as did some general practitioners (GPs) and social services care managers. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The home is cooperating with the improvement plans for its sister home nearby, and expansion and refurbishment of Brooklands 2 is planned for next year. This report identifies several requirements and recommendations. Some are to do with how the home has been reorganized to accommodate extra residents and relate mainly to health and safety. The Commission wrote to the proprietors after the inspection visit regarding the requirements needing immediate action, and the proprietors have taken appropriate action. What the service does well: Residents and relatives commented that staff members are responsive and caring. One relative said that staff members cared for his relative ‘exceptionally well’. Staff members come from a variety of cultural backgrounds, and one care manager commented that the home was able to look after the cultural and religious needs of a South Asian resident, with some staff members able to speak the resident’s language. The home’s terms of employment include the requirement for care staff to enrol on an NVQ programme, and 63 of care staff hold NVQ Level 2 or above. The home encourages oversees staff to add to their English language skills by facilitating language classes. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brooklands 2 DS0000046642.V317158.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 2 DS0000046642.V317158.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): 1, 2 and 3. The home does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although prospective residents’ needs are appropriately assessed before admission, all the necessary information about the home is not available to new residents through the home’s documents. EVIDENCE: Since the temporary room reorganisation at the home, the statement of purpose has not been updated, and therefore some of the information, such as the number and size of rooms and duties of staff is not accurate. Other important information, such as the reviewed fire procedure, must be included. The service user guide must be reviewed to give an accurate account of the home, the telephone number of the Commission must be included, and the ‘Complaints’ section of the guide should also be amended to show that the details of the Commission are contained within the home’s complaints Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 9 procedure. This is so that complainants do not need to ask the proprietors for the details of the Commission if they want to make a complaint. Although the proprietors circulated information about the new arrangements to residents and relatives before the reorganisation, the current situation must be reflected in the home’s documents so that prospective residents have all the information they need. The registered manager or Mrs Taylor, one of the proprietors, usually visits the prospective resident at home or in hospital to assess if the home can meet the resident’s needs. The pre-admission assessments for three residents were seen and contained information gathered from relatives, hospital staff and social service staff. The social service information was in the ‘summary of needs’ and did not contain a care plan developed by the social worker. Mrs Taylor explained the difficulty in getting this information from social workers, and this information would be very useful in determining if the home is able to meet the individual’s needs. Care plans are developed on admission, and the NHS contribution to nursing care for individuals at the home is assessed by an NHS nurse. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is poor. Proper provision is not always made for the care of residents, and prescribed medication is not always available if needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents can see their GP when they need to and are helped to keep hospital appointments when necessary. Opticians and a chiropodist visit regularly, and arrangements can be made for residents to see their dentist. Over half of the residents who completed the Commission’s comment cards said that they always received the care and support they needed, and several relatives commented that individual staff members were very caring and kind. Replies from relatives showed that the majority were kept informed of important matters affecting their relatives, but some said that results from doctor’s visits and other important events were not always communicated to them. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 11 The registered manager should review the system for communicating with relatives and should take action to make sure that all important information regarding residents is passed on to the resident’s representative, if appropriate. Residents can use the home’s mobile phone if they do not have a phone in their rooms, and staff members were noted treating residents with care and respect. The care plans and risk assessments for three individuals were assessed. Two nutritional risk assessment forms are in use, and this can cause confusion. It is recommended that only the form developed from the Malnutrition Universal Screening Tool be used, so that the evidence base of the assessment is known. A falls risk assessment for one individual concluded that the individual was at ‘high risk’, but there was no provision in the assessment form to show how the risk could be minimised, for instance, regarding appropriate footwear. The care plan showed that the individual needed to walk with an aid and needed supervision ‘at all times’, though there was no provision in the staff daily routine for this to be in place. The inspector noted that the resident was wearing slippers, was unsupervised for long periods during the morning, in one of the temporary lounges and in the dining room, and was walking unaided, risking a fall. The records of accidents show that there have been 25 falls in the home since June 2006, and it is not clear that appropriate action has been taken to minimise risks to residents. The registered person must make proper provision for the health and welfare of the residents, in accordance with the care plans. The care plans should make reference to current risk assessments, so that staff members have all the current information they need to care for residents. The registered manager must take advice from the Falls Prevention Service provided by the National Health Service regarding assessment, and should review the home’s falls risk assessment documents if necessary. The staff rota should reflect the needs of the residents, so that if an individual needs to be supervised at all times, this is reflected in the daily allocation of staff. All medications received into the home are recorded, but some medication prescribed to relieve pain when necessary for one resident was not available in the home, and had not been available for several days. Although the resident does not regularly need the medication, it must be available in case it is necessary. Some prescribed medication is not given at the appropriate time, with good reasons, but is not recorded appropriately. The registered manager must make sure that medication prescribed for a resident is available at the home. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 12 The registered manager should make sure that the nurses who do not administer medication at prescribed times must record that it has not been given, and should record the reason for not giving it as prescribed. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The activity organiser plans weekday activities for groups and individuals, and has a plan of activities, and residents’ views are considered when choosing the topics planned. Residents’ replies to the Commission’s comment cards showed that there were ‘always’ or ‘usually’ activities arranged that they could take part in. Records were seen showing good practice by the activities organiser, when following a care plan she became involved with one resident on a daily basis and helped to combat feelings of isolation and depression. There are plans to provide activities throughout the weekend next year as part of the home’s expansion. All but one of the relatives who responded via comment cards said that they were always welcome into the home. One relative needed to come early in the morning, and reported having difficulty with some staff members because of the early hour. This was discussed with the proprietors and this has been resolved. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 14 Relatives or staff members at the local Social and Health Care department are responsible for managing residents’ financial affairs, as none are able to manage themselves. Several residents told the inspector that the food was good, and the majority of residents’ replies to the comment cards showed that they ‘always’ or ‘usually’ liked the food. The inspector noted that some staff members were using dessertspoons to help residents to eat and one relative also commented on this practice. The inspector understood that when residents need a different utensil to eat their needs are documented in the care plans and discussed with relatives. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This is because although complaints are well managed and staff training to safeguard vulnerable adults is provided, the necessary clearance from the Criminal Record Bureau was not available about a recently recruited member of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home keeps a record of complaints, has a named person responsible for addressing complaints and follows the home’s procedure when addressing complaints. Most of the residents who responded to the Commission’s comment cards said they ‘always’ knew who to speak to if they wanted to make a complaint, and a comments/concerns box is available for relatives to use. Some relatives mentioned that they would like easy access to a complaint form, so that they can easily make their concerns known, and the proprietors are considering this suggestion. The Commission has received information since the inspector’s visit concerning lack of supervision for residents in the lounges, delays in responding to the call alarm in the lounges, several members of staff taking breaks together to the detriment of residents’ care, and no senior person available to make concerns known to. These concerns have been made known to the home and one of the proprietors has met with the complainants as part of the process of resolving the concerns. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 16 New staff members receive training about safeguarding vulnerable adults during induction, and the training is continued as part of the NVQ programme, and the Oversees Nurses Programme. Other staff, including nurses, receive update training as necessary. On the day of the inspection visit one recently recruited member of staff was working without the necessary clearance documentation from the Criminal Records Bureau and the home has since amended its recruitment procedures to make sure that all new staff members have clearance before they start work at the home. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 17 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, 25 and 26 Quality in this outcome area is poor. Residents’ health is put at risk due to the lack of water safety checks, and from potential risks from worn mats, which have not been recognised by the management. The poor management of the laundry causes problems for residents and relatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are plans to expand Brooklands 2 next year, and it is expected that the present building will undergo major changes so that accommodation, communal space and other rooms will be renovated and updated. A new laundry is planned to replace the present cramped laundry room. Some relatives complained about continuing problems with laundry, that woollen garments were often ruined and that clothing went missing. This may be because there are no staff members dedicated to managing the laundry, and Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 18 care staff members are responsible on a daily basis for laundry tasks as well as their care duties. Staff are given some training in managing the laundry, but the evidence shows that the laundry management should be improved. The residents who responded to the Commission’s comment cards said that the home was ‘always’ or ‘usually’ fresh and clean, though one relative complained that there was often a strong smell of urine in the main hallway. The inspector found a strong smell of urine on the top floor on two occasions during the visit, and the proprietors should take action to eradicate the smell. The carpet in one resident’s room was shabby and the rubber bedside mat was torn and worn. The mat was removed during the inspector’s visit. Although the intention is to upgrade rooms next year, the proprietors should conduct an audit in the near future of all the bedroom carpets and bedside mats to make sure that they are fit for purpose. The temperature of hot water from the hand washbasin in the top floor bathroom was 45 degrees Centigrade, though temperatures elsewhere in the home were at the appropriate level of close to 43 degrees Centigrade. At present the checks are carried out every two months and the inspector recommends that the temperature checks should be carried out more regularly, so that the fluctuations can be addressed quicker. The inspector understood that checks on the stored and circulating water to guard against Legionella infection are done annually. The proprietors commissioned a commercial firm to conduct the health and safety risk assessment for the new temporary arrangements, including the ramp to the temporary dining room and lounges, and it is not clear that any action arising from the assessment has been carried out, as the assessment was not available to the inspector. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is poor. The risks to residents left without carer supervision in the temporary dining and lounge areas were not recognised by the management, and it is not clear that enough staff are available for the temporary increase in resident numbers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the residents who replied to the Commission’s comment cards said that staff members listen and act on what they say, and that staff members were ‘usually’ available when needed. Of the relatives who responded to the Commission’s comment cards eight said that they did not think that there were sufficient numbers of staff members on duty, and an equal number thought that staffing was sufficient. On the day of the inspection visit, there was 1 registered nurse and six carers on duty in the morning, and one registered nurse and five carers on in the afternoon and evening. The administrator and one or both of the proprietors are usually in the home during office hours. At night there is one registered nurse and two carers. Carers are also responsible for the management of the laundry, though it is difficult to see how they can manage it well, as most of the residents need carers to help with personal care. The increase in resident numbers has meant an increase in the amount of laundry work, and it is not clear that this increase in carers’ work has been recognised. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 20 The accommodation of Brooklands 1 residents at the home has changed the environment of the home, and this has had an impact on the numbers of staff needed to care effectively for the residents. During the morning and daytime when residents are split between the home and the temporary dining room/lounge areas, staff need to be sure that the needs of the residents in both areas are met. The proprietors must conduct an assessment of the current staffing needs of the home, based on the needs of the residents during the day and the night, and provide appropriate staff to meet the current needs of the home. One of the proprietors conducted a risk assessment after the inspection visit concerning the safety of residents in the temporary areas during the day, and is implementing improved staffing levels as a result. The home’s terms of employment include the requirement for care staff to enrol on an NVQ programme, and 63 of care staff hold NVQ Level 2 or above. This is good practice, and residents and relatives commented that staff members are responsive and caring. One relative said that staff members cared for his relative ‘exceptionally well’. The home’s induction programme for new staff has been updated, and a new staff handbook developed, so that staff are clear about their duties. Three staff members’ files were seen to check the home’s recruitment procedure. The procedure is usually followed but one new carer was working in the home without clearance information from the Criminal Records Bureau regarding safeguarding vulnerable adults. This was understood to be due to an oversight in the administration, which is now corrected, and the proprietor took appropriate action to immediately address the situation. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is poor. The registered manager was not fulfilling her duties to residents regarding health and personal care, so putting residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is an experienced registered nurse and was away from the home at the time of the inspection visit. The findings in this report reflect on the competence of the registered manager, particularly regarding care planning, residents’ risk assessment and sufficient numbers and deployment of staff to meet the needs of the residents. The proprietors must consider how best to address accountability within the management structure of the home, and should develop and implement procedures to measure expectations. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 22 The home operates an annual quality assessment process, including questionnaires to relatives and residents. A relatives meeting was recently held, and a residents meeting is planned. The home does not manage petty cash on behalf of residents, and sends invoices for costs if necessary. All the registered nurses are trained in first aid, and contracts are in place with commercial companies to regularly carry out services on gas and electricity equipment. The fire officer’s last visit was in December 2005, and the recommendations from the visit have been implemented. The home has a health and safety statement and provides training and equipment for care staff to safely carry out their duties, and the proprietor carried out a health and safety assessment of the temporary arrangements before use by the residents. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 23 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 X 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 2 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 24 No 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 OP1 Regulation 6 Requirement The statement of purpose must be updated to accurately reflect the present arrangements at the home. The service user guide must be reviewed to give an accurate account of the home, and the telephone number of the Commission must be included. The registered person must make sure that the care plans are properly implemented to ensure the health and welfare of the residents. The registered manager must take advice from the Falls Prevention Service provided by the National Health Service regarding assessment of residents. The registered manager must make sure that medication prescribed for a resident is available at the home. The proprietors must conduct an assessment of the current staffing needs of the home, based on the needs of the residents during the day and the DS0000046642.V317158.R01.S.doc Timescale for action 30/11/06 2 OP2 5 30/11/06 3 OP7 13 30/11/06 4 OP8 13 30/11/06 5 OP9 13 25/10/06 6 OP27 18 30/11/06 Brooklands 2 Version 5.2 Page 25 7 OP31 24 night, and provide appropriate staff to meet the current needs of the home. The proprietors must consider how best to address accountability within the management structure of the home, and should develop and implement procedures to measure outcomes. 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP7 OP7 OP7 Good Practice Recommendations The care plans should make reference to current key risk assessments, so that staff members have all the current information they need to care for residents. The registered manager should review the home’s falls risk assessment documents and include how risks can be minimised. The registered manager should make sure that the staff rota reflects the needs of the residents, so that if an individual needs to be supervised at all times this is reflected in the daily allocation of staff. It is recommended that only the form developed from the Malnutrition Universal Screening Tool be used to assess risks of falling, so that the evidence base of the assessment is known. The registered manager should make sure that nurses who do not administer medication at prescribed times must record that it has not been given, and should record the reason for not giving it as prescribed. The registered manager should review the system for communicating with relatives and should take action to make sure that all important information regarding residents is passed on to the resident’s representative, if appropriate. The proprietors should take action to eliminate the periodic offensive smells in the home. DS0000046642.V317158.R01.S.doc Version 5.2 Page 26 4 OP8 5 OP9 6 OP13 7 OP26 Brooklands 2 8 9 OP19 OP25 10 OP26 The proprietors should conduct an audit of all the bedroom carpets and bedside mats to make sure that they are fit for purpose. The water temperature checks should be carried out more regularly than the present 2 monthly, so that the fluctuations such as that found on the day of the inspection visit can be addressed quicker. The proprietors should take steps to improve the management of the laundry. Brooklands 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 2 DS0000046642.V317158.R01.S.doc Version 5.2 Page 28 - 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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