Inspection on 14/07/06 for Brookside

This inspection was carried out on 14th 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brookside 19/12/05

Brookside 19/07/05

Brookside 20/12/04

Brookside 14/09/04

Brookside 01/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Brookside Giggetty Lane Wombourne Wolverhampton WV5 0AX Lead Inspector Dawn Dillion Unannounced Inspection 14th July 2006 13:30 Brookside DS0000033607.V304606.R01.S.doc Version 5.2 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 Brookside DS0000033607.V304606.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 Adults 18-65. 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. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookside Address Giggetty Lane Wombourne Wolverhampton WV5 0AX 01902 894485 01902 893167 julie.lindsayayres@staffordshire.gov.uk 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) Staffordshire County Council, Social Care and Health Directorate Mrs Julia Paula Lindsay-Ayres Care Home 16 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (2), Learning disability (16), Mental disorder, of places excluding learning disability or dementia (1), Physical disability (5) Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Brookside is a residential home owned by the Local Authority and is located in Wombourne, Staffordshire. The home provides a service for adults of both genders who have a learning disability. The two-storey property is divided into units and efforts have been made to provide an ethos of normal daily living within each unit. Each unit provides a lounge area, kitchen and bathroom and is equipped with furnishings to meet the needs of the service users. All bedrooms are of single occupancy and are tastefully decorated to reflect the individuals interests, there are no en suite facilities however; bathrooms and toilets are located in close proximity to both bedrooms and communal areas. Specialised equipments such as a hoist, nurse call alarm system and handrails are provided through parts of the home. The home is not suitable for individuals who have a physical disability, bedrooms are located on both the ground and first floor and there is no passenger lift in place. Service users have access to relevant healthcare services when required and are registered with a General Practitioner. There is a positive commitment to staff development and training, all staff are experienced within the care profession. The fees for the service provided at Brookside is £706.00p per week. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Key Inspection of Brookside was undertaken within five hours. The inspection methodologies used to establish the quality of care provided and the management of home entailed the examination of documents, policies, procedures and systems in operation to promote best practice. Information collated from the pre inspection questionnaire is also incorporated within the contents of this report. A tour of the property was also undertaken to ensure that the environment and equipments in use were suitable and safe to meet the needs of the service user group. During the process of the inspection three service users were interviewed to establish their views and experience in living at Brookside. Due to the complex needs and limited communication skills of a number of service users, the Inspector was unable to communicate effectively with other service users. The Registered Manager was not present during the inspection. The Care Manager provided assistance with the retrieval of documents required to conduct the inspection. Information obtained from service user comment cards and general observations during the course of the inspection identified that service users were satisfied with the service and provisions provided at the home. What the service does well: Service users person centred plans were well presented, providing essential information, relating to the individuals care needs, the level of support and intervention of relevant healthcare professionals, required to ensure that service users were able to live a style of their choice. Service users were actively involved in the management of the home, regular self-advocacy meetings were undertaken to ensure that service users were informed of any imminent changes with regards to staffing, building and routines within the home. Brookside DS0000033607.V304606.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. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality in this outcome area is “good.” This judgement is based on evidence obtained from previous inspection visits relating the homes admission procedure. Sufficient information was provided to prospective service users to enable them to establish whether the home would be suitable to meet their care needs. EVIDENCE: The Care Manager informed the Inspector that no service users had been admitted to the home since the last inspection visit. Previous inspection reports identified that all prospective service users were subject to a pre admission assessment; to enable the home to establish whether they would have the capacity to meet the individuals identified care and social needs. All prospective service users would also be offered a trial visit prior to being admitted to the home, giving the individual the opportunity to view the premises and to meet existing service users and the staff team. Information obtained from the pre admission assessment provided a framework for the development of the person centred plan and a risk assessment. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The quality in this outcome area is “good.” This judgement is based on evidence obtained from the examination of service users person centred plans, minutes of self-advocacy meetings, risk assessments and discussions with service users. Systems and procedures in operation ensured that service users needs were met in accordance to their plan of care. The home was also proactive in ensuring that service users were involved in decision making in areas affecting their welfare and lifestyle. EVIDENCE: A person centred plan was in place for each service user, providing detailed information about the individuals care needs and the level of support required to enable them to live a lifestyle of their choice. Where possible service users were actively involved in the development and review of their plan of care. Person centred plans were designed in a pictorial format to assist with service user understanding. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 10 Person centred plans were reviewed on a six monthly basis, with the intervention of relevant agencies to ensure that the changing needs of the service user was reflected within their plan of care. The home operated a key worker system; dedicated staff worked closely with the individual service user to provide consistency in the delivery of care. Self-advocacy meetings were undertaken on a monthly basis, the examination of minutes of meetings identified discussions relating to social activities, holidays, staffing arrangements, changes within the home and day care services. Risk assessments were in place for each service user identifying potential hazards and providing information relating to control measures to reduce or eliminate the identified risk. The Registered Manager is reminded that risk assessments should be reviewed more frequently to reflect the changing needs of the service user. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The quality in this outcome area is “good.” This judgement is based on evidence obtained from discussions with service users, the examination of contact sheets, menus and general observations during the process of the inspection. The staff team were proactive in providing a service that promoted independence and social inclusion, irrespective of the environment and the model of service of which was institutional. EVIDENCE: The examination of person centred plans, identified information relating to the level of support the individual service user required, to enhance and develop their daily living skills, to promote independence. The staff team were proactive in providing a service that promoted independence and social inclusion, irrespective of the environment and the model of service of which was institutional, having a large group of people living together. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 12 Discussions with the Care Manager identified that the home provided the necessary day activities for two service users during the week, of which consisted of swimming sessions, horse riding and other social activities and stimulation. The majority of service users within the home accessed day care services throughout the week, discussions with service users identified that day care services provided various activities and enabled them to access the local college to learn and develop new skills. The Inspector raised concerns with regards to the staffing levels provided within the home. The home was divided into four units; the examination of the rotas identified that on occasions only three care staff were provided. The Care Manager informed the Inspector that the current staffing hours were sufficient in meeting the care needs of the service user group and that additional staff were provided for planned social activities. Discussions with service users identified that the routine within the home was flexible and that they had freedom of movement throughout the building with some limitations due to health and safety. General observations during the process of the inspection identified that staff interacted and communicated with service users in a polite and respectful manner. Staffs approach promoted the privacy of service users. The examination of menus identified that a well-balanced diet was provided, however, there was no alternative choice reflected on the menu. Discussions with the Care Manager confirmed that service users were provided with a choice. It has been identified as a recommendation within the contents of this report that the alternative choice should be identified on the menu. There were no special diets required in relation to cultural or religious needs; the Care Manager informed the Inspector that a dietician was involved in providing professional advise and support, to ensure that service users nutritional needs were meet appropriately. A Speech and Language therapist was also accessible to service users who experienced difficulties with their swallowing reflexes. Specialist aids were also provided to assist service users with eating and drinking. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality in this outcome area is “good.” This judgement is based on evidence obtained from the person centred plans, risk assessments and the examination of the medication mar sheets. Service users were provided with the appropriate level of support and guidance to promote their mental and physical health. The homes medication system ensured that service users received their medication as directed by their doctor. EVIDENCE: A person centred plan was in place for each service user, providing detailed information with regards to the level of support and guidance required in maintaining the individuals mental and physical health. Discussions with the care staff and general observations during the process of the inspection, identified that the staff had a sound knowledge of the individual service users care needs, to ensure that they lived a fulfilled and active lifestyle. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 14 Each person centred plan contained a brief and concise 24-hour plan, providing information relating to the individuals chosen daily routine and areas where support and assistance would be required. Discussions with both the service users and staff and general observations during the process of the inspection, identified that there was a positive emphasis focused on individuality and to promote independence. The examination of the person centred plans, confirmed that service users had access to healthcare services and professionals for routine health screening. With reference to the medication systems in operation, the home used the Nomad monitored dosage system. Records relating to the administration, storage and recording of medicines were satisfactory. There were no controlled medicines or homely remedies in use. There were no service users within residence who were able to administer their own medicines. The Care Manager informed the Inspector that staff who were responsible for the administration of medicines had received training within this area. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality in this outcome area is “good.” This judgement is based on information obtained from the homes complaint policy and the examination of the homes recruitment procedure in view of systems in operation to protect the service users. The homes polices, procedures and practices ensured that service users views were listened to and acted on and that they were protected from abuse. EVIDENCE: The homes polices, procedures and practices ensured that service users views were listened to and acted on and that they were protected from abuse. There was a complaints policy in place that was designed in a pictorial/symbolic format to ensure that service users were aware of what to do if they had any concerns. Two files pertaining to staff working within the home were randomly selected for examination, all of which contained evidence that staff were subject to a POVA 1st and a Criminal Record Bureau clearance prior to the commencement of employment. Discussions with three members of staff during the inspection confirmed that they had a sound knowledge with regards to the protection of vulnerable adults. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The quality in this outcome area is “good.” This judgement is based on information obtained from general observation during the inspection of the property. Brookside was institutional in appearance and is located in the grounds of a special school, the location and design of the property does not promote normal daily living. The environment was safe and appliances in use were appropriately serviced/checked to ensure the health, safety and welfare of the service users and the staff group. EVIDENCE: Brookside was institutional in appearance and is located in the grounds of a special school, the location and design of the property does not promote normal daily living. The home is located in Wombourne, Staffordshire and is accessible via public transport and is also in close proximity to local amenities. Ample car parking was provided within the grounds. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 17 The two-storey property was divided into four units, providing accommodation on both the ground and first floor. All bedrooms were of single occupancy, en suite facilities were not provided however, toilets and bathrooms were located near to bedrooms and communal areas. The ground floor consisted of a lounge and a separate dining area, equipped with domestic style furnishings. The home also consisted of two flats, which were located on the ground and first a floor, both areas were equipped with adequate furnishings and items to provide a comfortable area. Discussions with the Care Manager and general observations during the inspection identified that the majority of service users were fairly mobile. An assisted bath was provided to promote the independence of service users who may have restricted mobility. There was also a hoist in place to assist with moving and handling of one service user. All meals were prepared and cooked within the home, a large well equipped industrial kitchen was in place. A laundry was situated at the rear of the property, equipped with adequate machinery, appropriate systems were in place to ensure hygiene standards and to minimise the risk of cross infection. Adequate heating and ventilation was provided throughout the home, it was pleasing to see that additional lighting had been provided within a number of bedrooms. The hygiene and cleanliness of the home was of a satisfactory standard. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 The quality in this outcome area is “good.” This judgement is based on information obtained from the examination of staff working rotas, training records and discussions with staff. There was a positive commitment to provide staff with the necessary training, to ensure that they had the appropriate skills and knowledge to undertake their identified role. Staffing levels were adequate with regards to the current dependency levels but appeared marginally inadequate on occasions where three care staff were provided for a home that was divided into four units. EVIDENCE: Staffing levels were adequate with regards to the current dependency levels but appeared marginally inadequate on occasions where three care staff were provided for a home that was divided into four units. The Care Manager informed the Inspector that when there were only three care staff on duty, the Care Manager would provide any necessary assistance, she was confident that the current staffing levels were adequate in meeting the needs of the service user group. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 19 As previously identified within the contents of this report the Care Manager informed the Inspector that additional staff were provided for planned social activities. The Care Manager informed the Inspector that the current staff vacancies consisted of two Support Worker posts, hours of which equated of 52 hours per week; the existing staff team covered the vacant hours. Two files pertaining to staff working within the home were randomly selected for examination both contained evidence that staff were subject to relevant safety checks prior to starting work within the home. The examination of training records and discussions with the staff confirmed that they had received the appropriate training in relation to their identified roles and responsibilities. It was pleasing to see that some staff had received equality and diversity training. There was no evidence of training relating to dementia care. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality in this outcome area is “adequate.” This judgement is based on information obtained from discussions with the service users and staff, the examination of staff files and training records, systems in operation that promotes the health and safety of service users and staff. The homes quality assurance system was also examined. A structured management team ensured consistency for the delivery of a diverse service delivery. The homes quality assurance system provided a positive emphasis with regards to providing consistency and a quality service. Appropriate systems and equipments were in place to ensure the health and safety of service users and the staff; the home was currently experiencing problems with water temperature and the malfunction of fire doors. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Registered Manager was not present during the inspection, the Care Manager provided assistance with the facilitation of the inspection. Previous inspection reports identified that the Registered Manager was experienced within social care and had obtained relevant training pertaining to her roles and responsibilities. Discussions with a number of staff confirmed that they received adequate support and guidance from the management team, who were described as approachable. Staff also confirmed that they received regular supervision and that the Local Authority was proactive in providing on-going training to ensure that they were appropriately equipped to undertake their respective roles. The examination of training records identified that staff had undertaken training relating to the management of violence and aggression, moving and handling, emergency first aid, food hygiene and blood borne transmittable diseases. The home has a registration category for dementia, discussions with the Care Manager identified that there was one service user within residence, with this condition. Staff had not received any dementia care training and there was no specific identification of a specialist service in relation to dementia care. Regular staff meetings ensured that staff were informed of relevant information, to ensure that the service provided to the service users was consistent and promoted equality and diversity. The homes quality assurance system provided a positive emphasis with regards to providing a quality service. A quality audit was undertaken on 11/10/05, the information collated from this audit generated an action plan to address any short fallings, to ensure that an effective service was provided. Systems and records that were examined relating to the promotion of the health, safety and welfare of service users and staff identified the following: The fire alarm system was checked on a regular basis, the last recorded checked was on 12/07/06. The homes fire fighting systems were serviced on 07/03/06. A current fire risk assessment was in place. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 22 On the day of the inspection a number of fire door closures were faulty, the Care Manager informed the Inspector they were in the process of addressing this problem. The Registered Manager is respectfully remained that the fire risk assessment should incorporate additional information relating to contingency plans whilst fire door closures were malfunctioning. The examination of records relating to water temperature monitoring identified temperature of between 31.8 – 55.2oC, the Care Manager informed the Inspector that they were currently experiencing problems with the water distribution. A plumber was working within the home on the day of the inspection. Brookside DS0000033607.V304606.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 24 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. 2. Standard YA35 YA17 Regulation 18 18 Requirement To ensure that staff receive dementia care training. The current catering hours should be reviewed to ensure a more effective and efficient service. (Outstanding from 01/05/05 and 01/04/06) To ensure that water distribution temperatures accessible to service users are regulated to a temperature of 43oC. (Outstanding from 20/02/06) The fire risk assessment should incorporate information relating to fire doors that were malfunctioning on the day of the inspection. Timescale for action 30/09/06 01/10/06 3. YA43 13 25/08/06 4 YA42 13 25/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 25 1. 2. 3. 5. 6. YA10 YA30 YA42 YA17 YA13 The homes confidentiality policy should be made accessible to the service users and their families. Training relating to infection control should be reviewed to ensure that information delivered to staff is up to date. Evidence of the servicing of gas appliances should be made available for inspection purposes. To ensure that menus identify a choice to reflect service users likes and dislikes. The Registered person should ensure that staffing levels are reviewed in the future, should the dependency levels of the service user group changes. Brookside DS0000033607.V304606.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Brookside DS0000033607.V304606.R01.S.doc Version 5.2 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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