Inspection on 30/05/06 for Brookside

This inspection was carried out on 30th May 2006.

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

Brookside 08/12/05

Brookside 11/04/05

Brookside 14/09/04

Brookside 13/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Brookside Ruskin Avenue Melksham Wiltshire SN12 7NG Lead Inspector Roy Gregory Key Inspection 09:30 30 May 2006 th 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 Brookside DS0000028405.V295310.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. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookside Address Ruskin Avenue Melksham Wiltshire SN12 7NG 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) 01225 706695 01225 703181 The Orders Of St John Care Trust Miss Eleanor Joan Walton Care Home 50 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (13), Old age, not falling within any other category (37) Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 13 service users with mental disorder or dementia at any one time. 8th December 2005 Date of last inspection Brief Description of the Service: Brookside is a purpose-built residential home for 50 elderly people, 13 of whom may have needs associated with dementia or other mental health issues. The home was formerly owned and run by the local authority, but has for some years been provided by the Orders of St John Care Trust, one of a number of homes provided by them in Wiltshire, Oxfordshire, Gloucestershire and Lincolnshire. Miss Ellie Walton was registered as manager of the home in June 2004. Accommodation is all in well-proportioned single rooms, located on two floors, with a passenger lift to the first floor. All bedrooms have wash hand basins and are located near to shared toilets. The home has seating areas rather than identifiable lounges. In addition there is an attractive enclosed garden with summerhouse and greenhouse. Three rooms are used exclusively for short stay residents. The home is situated in a residential area, a short walk from Melksham town centre, where shopping and social facilities are available. There are good bus links to neighbouring towns, whilst the home has its own adjacent car park. Weekly fee levels range between £390 - £460, dependant on assessed dependency. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit for this inspection was made on Tuesday 31st May 2006. The inspector, Roy Gregory, was at the home from 9:30 a.m. to 8:00 p.m. The registered manager, Miss Walton, was available for most of this time, whilst the inspector also spoke with two care leaders, the activities co-ordinator, the administrator, and members of the care and support staff teams. During the inspection there were also conversations with a visiting district nursing sister and with people visiting their relatives. A number of residents were spoken with, including sharing a lunch at table with three of them. All the home was toured, with a small number of individual rooms being seen. Prior to the inspection, pre-inspection information had been received from Miss Walton. Additionally, nine survey forms have been received from residents. During the inspection, documentation looked at included care records, training and recruitment documentation, risk assessments and fire precautions records. Medication storage and records were examined in detail, together with a discussion with the care leader with primary responsibility for this area of practice in the home. A number of instances of care giving were observed, and the inspector sat in on a staff shift handover. What the service does well: What has improved since the last inspection? Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 6 Four requirements made at the previous inspection have been complied with, resulting in more consistent completion of medication and staff records, and the making safe of some radiators that were not covered. Required improvements to sluice rooms, to achieve better infection control, have been budgeted for. A recommendation for better dissemination of activities information has led to monthly newsletter distribution to all residents, and clearer use of notice boards. 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 DS0000028405.V295310.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 Brookside DS0000028405.V295310.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 5 (Key Standard 6 does not apply to Brookside) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are only admitted to the home on the basis of a professional assessment that demonstrates their needs can be met. EVIDENCE: Residents who had recently moved into the home confirmed they had received good information. In fact, many had previous experience of respite stays, whilst others had made use of day care facilities or visited. One resident complimented staff on their sensitivity to moving and settling-in issues. Assessments, including information from care managers where applicable, were in place for permanent and temporary residents, and were used as the basis for care planning. An initial entry in one person’s notes drew staff attention to the fact that their “needs have changed slightly since the last period of respite care in February 2006”, showing out-dated assessments were not accepted. For all admissions, a dependency level was decided around the time of admission, to assist care planning and fee setting, and this was reviewed after the first month of residence, with the resident involved, at Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 9 which time the longer-term suitability of placement was also confirmed. Initial care plans were signed at the time of being written, either by residents or their representatives. At the time of inspection a place was being offered to a person currently in hospital in London. Miss Walton had not been prepared to rely on telephone information and had visited the person together with a care leader in order to carry out an assessment to their usual standard. Further, Miss Walton was endeavouring to reach agreement with the hospital that the person could return there if the initial review period in the home should not be successful. A relative of a resident admitted for respite had observed a full assessment and seen how this led into care planning. They considered their relative would have benefited positively from their stay. Brookside DS0000028405.V295310.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Individual care plans receive regular review and direct care across a spectrum of need. There is prompt awareness of and response to health needs, including excellent liaison with health professionals and emergency services. Systems and practice in handling medications are mainly good, but use of “as needed” medicines has not been sufficiently accountable to ensure it is appropriate and safe. The approach to the care task is based on respect for diversity and privacy. EVIDENCE: Four care plans were examined in detail, whilst others were cross-referred to other records such as notifications to the Commission and medication charts. All showed they were regularly reviewed and that they were living documents. Reference was made to care plans in staff handover. Miss Walton had been encouraging care staff to make entries in daily care notes that referred directly to care plan objectives, thereby facilitating reviews and liaison with outside agencies. This emphasis could be seen in practice, thus demonstrating that Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 11 care plans were being followed. Residents varied in their understanding of the ongoing care planning process, but consistently expressed trust in staff understanding of their care and health needs. A resident’s choice in how they were bathed had led quickly to a change of written plan to ensure their wishes were carried out. It was clear from spending time in the care office that staff had strong working relationships with health, social work and mental health agencies. Confidence in their liaison with GP surgeries, including readiness to suggest medication reviews or other courses of action, was reflected in the degree to which they were able to arrange doctors’ visits to residents. These in turn were well recorded, and sometimes showed tenacity in securing services where residents were dissatisfied with health outcomes. Notifications to the Commission of incidents and serious illnesses also show prompt awareness of and responses to medical emergencies, making full use of emergency services as necessary. A visiting District Nursing Sister described excellent liaison with the home, saying she never had worries about Brookside’s handling of health-related matters, including end of life care. Any concerns about pressure areas were brought immediately to district nurse attention, meaning preventive measures could be implemented, including provision of equipment where indicated. On this occasion, the nurse had been asked to see a resident admitted the previous day for respite care, where a member of staff had reported a possible concern through the staff handover. Accordingly, the nurse said serious pressure area problems did not arise in the home. All care plans contained an element for tissue viability. In one, for example, a reduction in mobility had been noted and triggered a request for a pressure-relieving cushion, and further care instructions had been added three weeks later. The inspector was struck by the quality of handover between shifts of care staff. As well as passing on significant changes and monitoring information, individual staff members contributed freely to the process. This gave rise to useful discussions, for example about a resident’s current stoma management. In consideration of a person’s psychological needs, their key worker acted effectively as their advocate, enabling the staff group to decide a course of action. From the meeting, the incoming care leader determined her priorities, as well as delegating tasks to staff. In many records, it was possible to track concerns on the part of carers translating into action by care leaders, and other professionals’ input as necessary. There were entries in multi-disciplinary records made directly by district nurses, physiotherapists and others, negating risk of instructions being “filtered” or misinterpreted. Through the day there was attention to replenishing jugs of water and juice available to residents. For a number, fluid or nutrition intake charts were in use and for all residents, weight records were kept regularly. Miss Walton said any significant weight loss always resulted in requests to GPs to consider prescribing nutrition supplements. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 12 Primary responsibility for the home’s medication administration procedures was currently being transferred from one care leader to another. Procedures were sound and included highlighting in drugs administration records of “as needed” medications and their purpose. The care leader agreed further safety would be engendered by incorporating guidance about individual “as needed” prescriptions in care plans, so that it can be clear in what circumstances they are to be given and whether it is resident or staff that initiates consideration of use. There is experience in the home of prompting medication reviews by GPs, and it was the intention that “as needed” pain relief prescriptions would be terminated when acute need was over, rather than being allowed to drift to remaining within the system for occasional use. Medication administration records were good, other than one discrepancy concerning an “as needed” medicine, which a care leader undertook to investigate at once. Some instances of excellent caring interactions were seen. Many residents said they felt they were treated with respect and sensitivity by staff at all levels. Brookside DS0000028405.V295310.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The home has developed regular activities provision that links with residents’ individual interests and capabilities, including provision for religious observance. Within daily life, residents are able to exercise many choices. Community and family contacts are encouraged. Meals are of good quality. EVIDENCE: A monthly newsletter, delivered to each resident, contained details of planned events such as trips out, music and talks, which were also publicised on notice boards. Additionally, the activities co-ordinator devised a weekly activities programme, which included during the week of the inspection visit, floor hoopla, reminiscence, mobile shop, exercise and board games. These were scheduled for times when she herself was not in the home. Shift handovers included delegation to one or two carers to run the planned activity, who then decided at what time they would fit it with other duties. During the activity coordinator’s time in the home (20 hours per week), her preference was for unstructured activities, allowing responsiveness to identified individual or group needs, the weather and so on. She aimed to ensure residents experienced occupation or engagement “little and often” and with spontaneity. For example, she would often take out residents for short walks or shopping, Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 14 or engage in one-to-one conversation, especially with those less inclined to join in group activity. She also had skills in triggering small group activity that could be left to run its own course. Residents and staff saw the activity coordinator as having had a big influence on increasing opportunities for socialising, and physical and mental stimulation. A resident’s relatives spoke of the effort of all staff in assisting their relative to join in activities of her choice. The co-ordinator has developed a picture of what activities are successful for different people. This was reflected in her contribution to care plans, all of which had social needs components. These were actively reviewed, for example one person was noted as having difficulties participating in previous activities due to health issues, and so their plan was amended to concentrate on ensuring one-to-one opportunities were made available. All people on respite stays, and residents with dementia, were given planned individual time. Such engagement in turn encouraged individuals to think about and exercise choices. The home offers day care through the week, with staff dedicated to that function. There was considerable mixing of day and resident service users. Some of the latter said they had begun their use of Brookside through attendance for day care, which had eased subsequent transition to residence. The midday meal shared by the inspector was of the high standard found at previous inspections. There was a choice of three hot meals, one of which was suitable for vegetarians. Two choices of sweet, plus ice cream, were complemented by diabetic versions. Several staff were available to serve the meal in a polite, unhurried way. The dining room had benefited from refurbishment and provided a pleasant setting, whilst service to individual rooms was also seen to be good. A resident whose mobility had declined made a daily choice of where to take meals, and appreciated that staff knew her preferences, for example how to cut up some of her meals because of some visual disability. All residents spoken to, including a short stay person, were very complimentary of all meals served. One wrote on a survey form “the meals are better here than in other homes where I have stayed.” Brookside DS0000028405.V295310.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is good provision for receipt of and response to complaints, which are used as tools for quality assurance. Staff and management understand and exercise responsibilities in respect of keeping residents safe. EVIDENCE: There had been four complaints received from residents since the previous inspection. Records showed these had been followed up in line with the provider trust’s complaints procedure, allowing tracking of the manager’s actions, including apologies made and learning points taken from them. A resident spoke to the inspector about a complaint they had made in relation to behaviours posed by a mentally frail resident; he accepted that management and staff were doing what was possible to manage the matter, and considered the complaint to have been responded to appropriately. In the home there has been experience in the past of working with local interagency vulnerable adults procedures. The revised guidance to these had not yet been received, and Miss Walton undertook to request copies at once. Access to the front door was controlled as a protective measure, whilst residents had ready access to a secure rear garden. A resident confirmed the option of locking his individual room, but preferred not to do so. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 16 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, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The environment provides for comfort, choice and safety, and is well maintained. Bedrooms are individualised and comfortable. There are high standards of hygiene. EVIDENCE: The home presented extremely well, having benefited from a programme of redecoration and re-carpeting in many areas. The handyman thought a point had been reached where ongoing maintenance, with the support of the Trust’s property department, should be straightforward. Many bedrooms had an array of personal possessions and items of furniture. Residents expressed satisfaction with their accommodation, although some considered the lack of en-suite toilets a compromise they had had to accept. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 17 There were no concerns by residents about cleanliness of the environment, and the inspector likewise found high standards, commenting only on a need for some high level cleaning in the hairdresser’s room. Housekeeper staffing is provided on all days of the week, whilst night staff have nightly and weekly cleaning duties to perform. Upgrades to the home’s sluice rooms, as required at the last inspection, had been provided for in the current year’s budget. Radiators in a suite of toilets, identified as posing risk of burn injury at previous inspection, had been covered. Some residents said they had been informed their radiators were to be changed, to enable them to use the temperature controls more easily. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 18 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 - 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staffing is sufficient to provide care in line with care plans. Turnover is low whilst motivation for training and development is high, resulting in consistent and skilled delivery of care. Recruitment practice is sound. EVIDENCE: The staffing budget had been increased and, whilst residents’ perceptions were of staff being overworked, staff themselves considered the additional hours, use of “care support” (for bed making, clearing breakfast trays etc.) and activities co-ordinator role had all made a difference. However, the consensus of a staff group of six was that the staffing level only just provided for the levels of dependency now commonplace in the home. Extra time was swallowed up by extra demand, and they were concerned that they had no greater opportunities to engage with the less dependant residents, who would therefore see them as busy and remote. Direct and survey feedback from residents about the quality of staff was universally positive. Those spending more time in their own rooms, for whatever reason, said staff regularly popped in to see them through the day. The manager and care leaders had received training in dementia care developed by the Alzheimer’s Society. Miss Walton had obtained resources to enable her to deliver the course, which is certificated, to staff in the home, with the assistance of a care leader. Staff proved to be highly motivated about Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 19 training opportunities, one sharing with the inspector about work she was undertaking on communication in association with NVQ training. Of a total of 38 care staff (including night staff and relief staff), 15 were qualified to NVQ in care to level 2 or 3, with a further 7 working towards this. It should also be pointed out that a number of ancillary staff also have NVQ in their respective fields. Only two new staff members had been recruited since previous inspection. There were no concerns about recruitment practice, and as required at previous inspection, photos of all staff were now being kept. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 20 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, 32, 33, 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. There is effective delegation and participation between management and the care staff team. The manager sets high standards and gives a lead to how these can be attained. Residents experience an open style of management, with good channels of communication and provision for safeguarding financial interests, where required. Provision for health and safety is excellent. EVIDENCE: The way in which Miss Walton presented the requested pre-inspection material was typical of her attention to detail and systematic approach. Staff at all levels spoke of Miss Walton’s encouragement to aim for the highest standards and values, and she was considered to lead by example. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 21 It was commendable that during a period when the passenger lift was out of action for upgrade for over two weeks, extra staffing was provided, including agency staff (unusually for Brookside). This allowed at night for a member of staff to be permanently located on the upstairs landing, whilst by day, a vacant upstairs room was converted as a temporary sitting room, with staff support, for those residents unable to access downstairs. Other measures were also put in place as a result of a full risk assessment and management plan. Similarly, replacement of carpeting in communal areas downstairs was planned for by risk assessment. Miss Walton had successfully argued that much of the work should be undertaken at night, despite the greater costs of doing so, to minimise risks and inconvenience to the residents. In both instances, it was necessary to ensure safe and efficient service of meals and administration of medicines. Other examples of good provision for health and safety were provisions for safe use of oxygen, and individual room risk assessments. Residents and their visitors considered themselves well informed of matters in the home by the monthly newsletter delivered to each room, by notice boards and residents’ meetings. A meeting was planned for 31st May and was well publicised, with a number of residents informing the inspector of their intention to attend. One resident spoke of membership of a residents’ committee, which he described as an effective exchange of information. There is also ongoing monitoring of management and care outcomes for residents by way of the provider Trust’s quality assurance systems, which include regular unannounced visits. An anonymous survey carried out among residents and families in 2005 had produced evidence of overwhelming satisfaction with the operation of the home. Nevertheless, Miss Walton had seen the addressing of a few negative observations as a priority task. There was no change to the satisfactory arrangements for safe keeping of residents’ monies, where they or their families had requested this. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 22 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 3 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 4 4 4 X 3 X X 4 Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 23 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 There must be a care plan in respect of any medication prescribed “p.r.n.” or selfadministered. Timescale for action 31/07/06 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 There are no recommendations from this inspection. Brookside DS0000028405.V295310.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 DS0000028405.V295310.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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