Inspection on 04/07/06 for Brooklands

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 17/07/07

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 Rebecca Shewan Unannounced Inspection 4th July 2006 09:20 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.V290163.R01.S.doc Version 5.1 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.V290163.R01.S.doc Version 5.1 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 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.V290163.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 7th February 2006 Date of last inspection 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 for 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 £750 - £780 per week, with additional charges made for newspapers, hairdressing and chiropody. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 4th July 2006 and the morning of the 18th July 2006. Incident reports, Monthly unannounced monitoring visit reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took eight and a half hours. A tour of the whole home was undertaken and the Registered Manager, eight staff, five service users (known as Residents), one General Practitioner (GP) and four relatives/representatives were spoken with. Records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Ten Service User Surveys were distributed of which were returned. Comments received included: • • • • ‘Its not like being in your own home but if you have to be in one of these places, this is definitely it!’ ‘There is a high turn around of staff but that’s to be expected in a home of this size’ ‘I like living here, it’s like one big family’ ‘The food is good and there is always plenty of salad, even when it’s colder weather’ Twenty-nine residents were accommodated at the home at the time of the inspection. What the service does well: The home ensures that thorough pre- admission assessments are carried out on all new and potential residents with only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Activities are arranged according to resident choice. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 6 There is an efficient complaints procedure in place and the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. The management and administration of the home is good, with evidence of consideration being given to resident’s and/or relatives opinion. What has improved since the last inspection? What they could do better: Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 7 The home must ensure that urgent action is taken to ensure that all handwritten entries onto medication Administration Record (MAR) sheets, are explained, signed and dated by the person making the entry, that the use of medication omission codes are explained on the back of the MAR sheets and that the use of white correction fluid on Mar sheets ceases. The home must ensure that its Adult Protection policy reflects the East Sussex County Council Multi-Agency Procedures for the Protection of Vulnerable Adults. The home are also advised to ensure that the homes Complaint Policy is updated to reflect that Adult Protection matters will be referred to Social Services (the lead agency in such matters). The home are also advised to ensure that the home is assessed by a qualified Occupational Therapist and that 50 of care staff are trained to at least NVQ level 2 in care by December 2005. These recommendations are outstanding from previous inspections. 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. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: The home’s Registered Manager, Deputy Manager or a Senior Nurse carries out pre- admission assessments. Records inspected showed that pre- admission assessments are carried out on all new and potential residents. It was noted that the documentation allows the assessor to gain a good overview of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority. The home has made improvements to ensure that any resident returning to the home following a stay in hospital are reassessed prior to being readmitted to the home. Relatives confirmed that they had been involved in the assessment process and had felt included in their relative’s admission to the home. Service user’s commented how they had ‘felt Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 10 encouraged’ at the time of their assessment that they were entering a friendly home. Intermediate care is not offered by this home. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvements are required to ensure that medication records are maintained appropriately in order to prevent the risk of errors being made by staff when administering medication to residents. EVIDENCE: Following the previous inspection of 7th February 2006, the home has made improvements to ensure that residents’ psychological social and all resident’s health care needs are detailed within the plans of care. Four residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Residents informed the inspector that care plans are devised with their involvement. Since the inspection of February 2006 improvements have been made to ensure that suitable risk assessments are in place for the complications associated with reduced mobility, trip/falls hazards and associated risks. These Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 12 risk assessments have been written in accordance with guidelines produced by the Department of Health the National Institute for Clinical Excellence (NICE). The home has access to a Tissue Viability Nurse who advises the home about pressure area sore prevention and maintenance of pressure area sore dressings. This was evident from the care plans viewed. From the records sampled and from discussions with staff and the GP, it was evidenced that the health needs of residents are well met with evidence of good multi disciplinary working taking place, on a required basis. The Registered Manager said that residents have a choice of GP of their own choice or one from the local surgery. Resident’s are encouraged to attend the GP surgery were able and home visits are conducted when necessary. It was observed that the home has a good working relationship with the local GP practice. The GP reported that the home are well informed and work cohesively with the GP practice, in order to ensure that the residents benefit from all health professionals input. Referrals to the Occupational Therapist, Physiotherapist and Audiologist are made via the GP or the hospital. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. The home has made improvements since the inspection of February 2006 to ensure that the medication procedure has been updated to reflect current practice. The controlled drug register and controlled medication were audited and were found to be correct. However, the medication administration record (MAR) sheets were viewed and it was evidenced that some improvements are required, to address the manner in which staff record medications either administered or non- administered. It was evidenced that where medication had been omitted, the recording for the reason of this omission was not clearly recorded, with the code ‘O’ being recorded without an explanation being recorded onto the back of the MAR sheet. Some handwritten entries were also noted and it was evidenced that these were unsigned, undated and that no explanation had been given on the back of the MAR sheet. On two of the MAR sheets viewed white correction fluid had been utilised to make alterations to medication doses. Therefore immediate requirements were made. The home are currently liaising with the GP surgery and the local Primary Care Trust (PCT) to develop an approved system for the storage of stock Controlled Drugs within the home, this will enable the home to have access to such medication if it is prescribed out of hours and prevent a delay in the resident receiving it. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Of the six service user surveys received five stated that they always received the care and support that they needed, whilst one responded that they usually received the care and support that they needed. One respondent commented that ‘care and support is always provided to not only the resident but to visiting family members as well’. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a balanced diet to residents, with resident’s choice and wishes being respected. EVIDENCE: Resident activities are arranged and altered according to resident’s requests. The home does not have a published list of weekly activities. The Registered Manager said that resident’s attendance to activities was low and that residents are quite private and prefer 1:1 sessions. The home regularly has ‘pat dog’, ‘Extend’ (gentle exercise and movement) classes and a Reminiscence Therapist visiting the home. Residents are free to participate in activities, held by the home or within the local community, or not as they wish. Of the six service user surveys received one responded usually and three responded sometimes to the question that asks ‘are there activities arranged by the home that you can take part in?’ One survey was left blank and the remaining one stated ‘haven’t ever joined in any activities – so cannot comment’. Resident’s religious wishes are observed and arrangements are in place for residents to receive non-denominational Holy Communion if they wish. Discussions with the Registered Manager highlighted that although many of the current residents fall into a specific age group and have similar religious Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 14 beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. This was observed on the day of the inspection and confirmed by relatives/representative spoken with. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. Residents reported that the home assists them to maintain their independence with their daily living and daily routines. The home’s menus are devised on a four week rolling programme. The menus viewed showed that there is a variety of food and that the menus are varied. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and resident’s guests are also welcome to have meals at the home. The home’s chef confirmed that food questionnaires are sent o residents on a six monthly basis and that issues raised are addressed. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times and the home are actively encouraging residents to take extra fluids in the hot weather. Resident’s spoke of how they enjoyed being able to take their lunchtime meal on the veranda of the home, especially in the recent warm weather. Of the six service user surveys received four responded usually, one responded sometimes and one was left blank to the question that asks ‘Do you like the meals at the home?’ Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has received four complaints within the past twelve months, all of which have been recorded as addressed within the twenty-eight day response time as specified by the home’s policies and procedures. Each of the five complaints have now been resolved and appropriate action was taken by the home to address the concerns raised. From the section in the service user surveys received relating to complaints, this showed that five ‘always’ knew who to complain to and one responded ‘usually’. One resident commented that they do they do know who to complain to but that to date it has not been necessary. The home has a complaints procedure in place, however this will need amending to reflect that Adult Protection matters will be referred to Social Services (who take the lead in such matters) and not to CSCI. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Verification of nursing staff’s registration to practice is obtained from the Nursing and Midwifery Council (NMC) prior to nursing staff commencing employment. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 16 of abuse, they would know the correct procedure to follow. The home has a copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. Following the inspection of February 2006, the home has introduced a new Adult Protection policy, however this will require reformatting to ensure that it reflects the East Sussex County Council MultiAgency Procedures for the Protection of Vulnerable Adults. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides a good quality of accommodation for residents that is safe, hygienic and odour free. EVIDENCE: The home is well maintained and all areas of the home, including the garden, are accessible to residents. Of the six service user surveys received five responded always and one responded usually to the question that asks ‘Is the home fresh and clean?’ One respondent commented that ‘the home is maintained to a high standard’. A previous inspection recommendation that an assessment of the premises and facilities should be undertaken by a qualified Occupational Therapist (OT), to advise on the suitability of disability equipment and environmental adaptations has not been conducted. The Registered Manager said that the home were in the process of obtaining the services of an OT assessment, as are the homes Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 18 partner home Barons Down, and that some problems had been encountered due to the limited resources of the OT department. The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records, by staff spoken with and by observation of staff adhering to procedures. The home was odour free throughout. It was evidenced that a clinical waste contract is in place. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team, sufficient in number, meets the resident’s needs. There is a staff rota in place, which was made available to the inspector with the home’s pre-inspection questionnaire. Of the six service user surveys received four responded yes and two responded usually to the question that asks ‘Are the staff available when you need them?’ The home’s Deputy Manager is a trained NVQ Assessor. The home has a permanent care staff team of sixteen care assistants, one of which is trained in National Vocational Qualification (NVQ) level 2 in care and one is currently undertaking the NVQ kevel 2 course. The Registered Manager reported that a further five care staff are due to commence NVQ training in the near future. This was confirmed in the homes Pre-Inspection Questionnaire and from staff training records viewed. Therefore the previous inspection recommendation that a minimum ratio of 50 of care staff have achieved a NVQ in care by 2005 remains unmet. The home’s Deputy Manager is a trained NVQ Assessor. The Registered Manager said that a number of care staff are employed by the home who are either Registered Nurse qualified in the UK and are employed as Senior Carers or have a nursing qualification from their native country. A discussion was had between the Registered Manager, the Deputy Manager and Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 20 the Inspector with regards to how the home may have these staff assessed to ascertain that their qualifications are equivalent to an NVQ in care Level 2 or 3. Staff recruitment files were viewed and it was evidenced that the home has made improvements to the manner in which these files are maintained following the inspection in February 2006. It was evidenced that these files now contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities. A number of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. Staff training files have recently been redesigned to follow the guidance detailed by Skills for Care. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Medication Training, Fire Training, Health and Safety, Moving & Handling, Infection Control and First Aid. Other training related to the needs of the resident’s such as Tissue Viability, Caring for People With Dementia and Understanding nutrition have also been undertaken. Registered Nurses spoken with at the time of the inspection said that they felt the training provided was good and provided them with the opportunity to achieve their Post Registration Education and Practice (PREP) requirements, as governed by the NMC. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to residents choice and opinion with the health, safety and welfare of residents and staff being protected at all times. EVIDENCE: The Registered Manager has many years relevant experience in caring for older people. The Registered Manager is a qualified Registered Nurse and has achieved the NVQ level 4 in Management. Residents, relatives and staff spoken with said that the Registered Manager is friendly, approachable and any issues raised are actioned quickly and efficiently. There is a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Organisation. Quality Assurance questionnaires are distributed to residents, Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 22 their representatives and other interested parties on a six monthly basis. The results of which are not published but are made available to all upon request. Monthly unannounced (Regulation 26) visit reports are conducted and a copy of this report is sent to the CSCI Eastbourne Office. Staff meetings are held three times a year. Minutes of Staff meeting were viewed and these were found to be detailed in content and included actions taken to address previous issues raised by staff. The Registered Manager reported that Residents and Relatives meetings are not held as a matter of course, that previous attempts to conduct these have resulted in low attendances. The home has at least two events a year that all parties are invited to attend and attendance is high, the Registered Manager said that this is usually when the most feedback is obtained. The Registered Manager reported that the home does not take any responsibility for resident’s finances. Following the inspection of February 2006 the home has made significant improvements to ensure that a system for the safe keeping of resident’s jewellery is now in place. Detailed receipts are maintained of all items of jewellery given to the Registered Manager and two witness signatures are obtained. The home’s maintenance files were viewed and it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. Accidents are well documented in the home’s accident book. Fridge, freezer and food temperature probe readings are recorded on a daily basis. Following the inspection of February 2006 the home has made improvements to ensure that detailed risk assessments are maintained for all risk areas such as fire and external premises risk assessments. Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 X X 3 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 3 X 3 X X 3 Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 24 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 OP9 Regulation 13 (2) Requirement That all handwritten entries onto medication Administration Record (MAR) sheets, are explained, signed and dated by the person making the entry. This is an immediate requirement. That the use of medication omission codes are explained on the back of the MAR sheet. This is an immediate requirement. That the practice of using white correction fluid on MAR sheets ceases. This is an immediate requirement. That the homes Adult Protection policy is amended to reflect the East Sussex County Council Multi-Agency Procedures for the Protection of Vulnerable Adults. Timescale for action 04/07/06 2. OP9 13 (2) 04/07/06 3. OP9 13 (2) 04/07/06 4. OP18 12(1)(a) 13(6) 04/09/06 Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 25 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. Refer to Standard OP16 OP22 Good Practice Recommendations That the homes Complaint Policy is updated to reflect that Adult Protection matters will be referred to Social Services (the lead agency in such matters). It is recommended that the home is assessed by a qualified Occupational Therapist (This is outstanding from the last 3 inspections). It is recommended that 50 of care staff are trained to at least NVQ level 2 in care by December 2005. (This is outstanding from the last inspection). 3. OP28 Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brooklands DS0000013968.V290163.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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