Inspection on 04/01/07 for Brookside Court

This inspection was carried out on 4th January 2007.

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 Court 23/02/09

Brookside Court 04/01/06

Brookside Court 12/08/05

Brookside Court 25/11/04

Brookside Court 02/09/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

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

CARE HOMES FOR OLDER PEOPLE Brookside Court Cademan Close Knighton Leicester Leicestershire LE2 3WT Lead Inspector Rajshree Mistry Key Unannounced Inspection 4th January 2007 09:15 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 Court DS0000037671.V326044.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 Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookside Court Address Cademan Close Knighton Leicester Leicestershire LE2 3WT 0116 2706942 0116 2706944 brookside-court@leicester.gov.uk socis209@leicester.gov.uk Leicester City Council 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) ** Post Vacant ** Care Home 24 Category(ies) of Dementia (16), Dementia - over 65 years of age registration, with number (16), Learning disability (2), Learning disability of places over 65 years of age (2), Mental disorder, excluding learning disability or dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (8), Old age, not falling within any other category (24), Physical disability (3), Physical disability over 65 years of age (3), Sensory impairment (2), Sensory Impairment over 65 years of age (2) Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. All persons admitted to Brookside Court may only be accommodated on the first floor within the premises registered to Leicester City Council. No person to be admitted into Brookside Court under categories DE(E) or DE when there are 16 persons in total of those categories/combined categories already accommodated within the home. No person to be admitted into Brookside Court under categories MD(E) or MD when there are 8 persons in total of those categories/combined categories already accommodated within the home. No person to be admitted into Brookside Court under categories SI (E) or SI when there are 8 persons in total of those categories/combined categories already accommodated within the home. No person to be admitted into Brookside Court under categories PD(E) or PD when there are 3 persons in total of those categories/combined categories already accommodated within the home. No person to be admitted into Brookside Court under categories LD(E) or LD when there are 2 persons in total of those categories/combined categories already accommodated within the home. All persons admitted into Brookside Court may only be accommodated for a maximum period of 84 days from the point of admission into the home as stated within Brookside Court’s Statement of Purpose No one falling within category OP may be admitted into Brookside Court where there are 24 persons of category OP already accommodated within the home. The maximum number of persons accommodated within Brookside Court is 24 Up to 3 service users between the ages of 18 and 65 can be admitted to Brookside Court 4th January 2006 Date of last inspection Brief Description of the Service: Brookside Court Intermediate Care Unit is registered to accommodate up to twenty-four residents and is owned by Adults and Housing Department, Leicester City Council. The home is registered to provide personal care in a rehabilitation and intermediate care setting. Brookside Court is located in the residential area of Knighton, close to shops, pubs, the post office, churches and other local amenities. Leicester city centre is a short journey from the premises and is accessible by car or public transport. Car parking is available to the front of the home. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 5 The premises consist of two floors with level entry access. The upper floor is accessible via the passenger lift and stairs. There is a dining and choice of lounges. Bath/shower rooms, washing and toilet facilities are accessible and close to bedrooms and communal areas. There is a designated area for intermediate and rehabilitation service. There is a large therapy room used by residents under the guidance of therapists and health care professionals. The maximum weekly fee is £373, information received before the inspection and confirmed on the day. There are no fees payable for people admitted for rehabilitation or intermediate care. There are additional individual expenditure such as personal toiletries, hairdresser, chiropody, Optician and Dental care; newspapers, magazines, television licences, taxis and the fee will depend on the services received. Information about the Brookside Court is located at the main entrance detailing the range of services offered, which includes the Statement of Purpose. A copy of the latest Commission for Social Care Inspection reports (CSCI), inspection report is located in the foyer with the displayed registration certificate. The residents are informed of the findings of the CSCI inspection at the ‘Residents Meetings’ or individually. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspected the Brookside Court using the method ‘Inspecting For Better Lives’, which is based on outcomes for the residents. The inspection process consisted of pre-planning the inspection, reviewing the last inspection report and the reviewing of the Pre-Inspection Questionnaire and the history significant events. Comment Cards/Surveys distributed to General Practitioners and District Nurses by the CSCI and Comment Cards for the residents were given to the Assistant Manager on the day of the site visit. The unannounced site visit commenced on the 4th January 2007 and lasted 1 day. The method ‘case tracking’ was used to assess the outcome for the residents. This involved identifying residents with varying levels of care needs and looking at how these are being met by the staff at Brookside Court. Four residents were selected, of which, two receiving rehabilitation care. Discussions were held with them and the relatives of a resident to ascertain their views about the care provided. Discussions held with therapists involved in the rehabilitation of residents at Brookside Court such as Occupational Therapists and Physiotherapists and viewed residents records. Residents individual care records were viewed; discussions with rehabilitation assistants, herewith known as care staff, with varying responsibilities within the home and reviewing the health and safety records, training records and the minutes of residents and team meetings. Comments received from the General Practitioners indicated that they are well informed; staff demonstrated a clear understanding of care needs of residents, managed medication appropriately and no had complaints. Overall, the General Practitioners were satisfied with the care provided to the residents in the home. There were 70 of Comment Cards received from the residents, of which some were completed with the assistance from their relatives. The majority of the comments received were complimentary about the care received and the staff. Comments incorporated within Service User Comment Cards included: “He will miss it when you go home” “Very pleased with home” “Been very happy staying here” “Very good happy here would recommend to others” “Nice people are friendly” Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 7 “Likes the company of others and friendship” “Very enjoyable” “Staff always on hand to give whatever your needs, to give assistance where needed” “1st class” “Have never had any cause to make any complaint about anyone at this home” “All the staff here try to make it a home from home and assist your stay here as pleasant as possible” “Staff & home very supportive” “Best place I’ve stayed at” What the service does well: What has improved since the last inspection? Following the retirement of the Registered Manager, an Acting Manager was appointed. A Kitchen Assistant has also been appointed. Brookside Court has changed the registration to now accommodate up to 3 younger adults. The ‘Residents Questionnaire’ has been updated to seek the views of the residents staying at Brookside Court. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 8 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 9 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 Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care and rehabilitation needs are well assessed and consulted before they move into the home to ensure their needs can be met. EVIDENCE: Brookside Court did not have an up to date Statement of Purpose, reflecting the changes in the management of the home. This was brought to the attention immediately with the Assistant Manager to address. A copy of the revised statement of purpose was sent to the Commission after the site visit. The information about the aims and objectives of Brookside Court remains the same, which is to provide short stay or rehabilitation programme. The document contains information about the key policies and procedures including the complaints procedures. The whole document is in an easy to read style and concise. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 11 The admission procedure viewed for four residents tracked. The admission process is initiated by the assessment completed by the multi-disciplinary team of health and social care professionals, which is part of the referral process. These may include social workers and therapists such as occupational therapists, physiotherapists and speech and language therapists. The assessment is thorough containing key information as to the residents’ mobility, special or cultural diets and meals, communication needs, mental wellbeing to inform the rehabilitation needs and the health care provided by the District Nurses. Residents said they were informed the rehabilitation service provided at Brookside Court before moving in. Residents said they or their relatives were involved in choosing to move into Brookside Court and involved in the admission process to ensure their needs would be met during the short stay. Residents admitted for rehabilitation said they met with the therapists to look at their individual needs. Relative said their relative living at Brookside Court has been rehabilitated and is ready to go home. Staff said they were informed of new residents and their needs at the handover meetings daily. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are well cared for having their tailored health and rehabilitation needs met by a team of trained staff, to regain and promote their independence. EVIDENCE: The care plans for four residents were viewed, two receiving rehabilitation and two on interim (short) stays. The care plans were tailored to the resident as an individual, detailed and well written showing how all aspects of the resident’s health; daily living and rehabilitation needs should be met. Exercises and the rehabilitation programmes are kept with the care plan and placed in the resident’s bedroom. The care plans for residents not receiving rehabilitation show the level of assistance required with some reference to disabilities or impairment such as poor hearing or sight. Residents said their views and wishes were included in Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 13 the care planning. Key information such as preferred routines, living arrangements and cultural needs are also included. Care plans gave information in relation to identified risks and how these should be minimised. Residents were seen doing rehabilitation exercises sat in the lounge or in the therapy room. Occupational therapists said the assessment, programme of rehabilitation developed is done with the resident, and care staff are informed. Weekly meetings are held with the care staff to update on residents progress. The detailed daily records showed how the residents care needs and rehabilitation needs were met, by care staff. The therapists and care staff said they update each other when changes occur and regularly meet to exchange progress information. Records seen, observations made and discussion with the staff indicated resident’s needs were being met timely; staff were knowledgeable and well informed, especially with changing needs of the residents. Residents were able to describe how care staff supports them with daily tasks such as bathing and choosing their clothes. Observations made during the inspection showed care staff are vigilant to needs, interacting with residents and responding to call bells promptly. The Inspector saw residents being assisted to their bedroom to meet with the District Nurse. Care staff were seen addressing residents by their preferred names, being near to residents when speaking with them. One resident said care staff always respected her dignity when bathing or being transferred from the chair to wheelchair. Care staff were heard addressing by their preferred name. All the care files viewed contained good evidence of the involvement of General Practitioners (GP), District Nurses, Chiropodists and Optician and details of any treatment and instructions for care staff to follow. Discussion with the staff indicated that there was good communication between the home, the District Nurses and therapists. Residents said that they have seen their GP when requested or in an emergency. Medication is kept securely in the medication room, in a locked medication trolley. Assistant Manager said trained staff are responsible for managing and administering medication. The staff training records showed staff receiving training in safe handling of medication. At lunchtime, the Assistant Manager was seen giving medication to residents individually and completing each record. Resident’s photographs are placed in front of each medication record. The medication checked against the medication records for four residents tracked and other resident, showed records were correct and up to date. The manner in which residents were offered their medication was respectful and unrushed. All the residents said who spoke to the Inspector confirmed that they receive medication in a timely manner. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to regain their ability, independence whilst having their social and care needs met to suit their preferred lifestyle. EVIDENCE: The residents have a choice of lounges on the first floor and a large dining room on the ground floor. Residents were seen receiving visitors throughout the day. Some residents were seen reading the daily newspaper, watching television and enjoying conversations with other residents and care staff. Residents were aware that their stay at Brookside Court was only for a short stay albeit until care arrangements were in place or rehabilitation. Information received before the inspection indicated that residents are offered social and cultural activities of interests. The notice board in the main entrance listed these events for the week. On the day of the site visit the hairdressing was visiting and many of the women residents were having their hair done. Residents said they were asked if they had any preferences of having Holy Communion. Assistant Manager said although no regular church service, Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 15 private communion could be arranged upon requests. Brookside Court now has younger residents and there are no social or leisure activities to suit. This was discussed with the Assistant Manager, to consider developing social and leisure activities that would appeal to the younger residents. Residents receiving rehabilitation were seen doing their exercises whilst sitting in the lounge, therapy room and in the ‘assessment kitchen’. Residents were seen moving around the home without restrictions, meeting with their relatives in private and asking for help when needed. Residents’ said care staff were very helpful, described how they were supported them to make daily choices and encouraged to do their exercises. Some residents felt that care staff had helped them settle into the home quickly and helped them with their rehabilitation. Care staff were aware of residents preferences and routines. Residents were aware of their right to look at their care file at any time. The care plans viewed showed the resident’s interests, hobbies, goals and the involvement from family. Residents’ specific cultural needs and special diets such as diabetic, soft meals and cultural meals were detailed and known to the staff. Residents were asked as to their views of meals within the home. All the comments received were positive and complimentary about the quality of meals. Meals are prepared on the premises by trained cook and kitchen staff. Kitchen Assistant said a list of residents and preference of meals is provided daily as residents leave and new residents arrive. The list of residents showed the dietary needs, majority of the residents choose from the menu, whilst mobile meals are provided for residents preferring Asian and Afro-Caribbean meals. The Inspector observed residents using specially adapted cutlery and plate guards. The Occupational Therapist helped a resident with using the adapted cutlery. The majority of residents enjoyed a choice of chicken and mushroom or cottage pie with vegetables and a choice of deserts. Meals are served at the dining tables and residents seen helping themselves to the vegetables. Care staff were observed responding to residents requests in a discreet and responsive manner. Residents were heard being offered a choice of both main course and dessert. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Brookside Court’s complaints procedure is displayed in the reception area. The complaints procedure is available in other languages, symbols and formats. Advocacy Services contact details are also displayed on the notice board in the reception area. Residents and their relatives said they were informed of how to complain when they arrived at the home and received the home’s brochure. Residents said they felt confident to complain directly or through their relatives, staff on duty or the managers. Residents said they were asked frequently if they are satisfied with the programme of rehabilitation and care provided. The complaints log showed one complaint was received. Records showed the content of the complaint, actions taken to address the complaint how and when the complainant was informed. No expressions of concerns were expressed to Commission for Social Care Inspection regarding Brookside Court. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 17 Staff spoken with had a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and was confident to whistle blow on poor or bad care practices. Staff files seen contained evidence to show that staff have received training in safe guarding adults initially through the local authority programme of induction training, and as part of attaining a National Vocational Qualification (NVQ) in care. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ generally benefit from having a clean, safe and maintained accommodation, which individually and collectively meets the residents’ needs. EVIDENCE: Brookside Court is well maintained, decorated and furnished to a good standard, providing a comfortable and homely environment. The corridors are well lit with handrails to help residents. The garden and the surrounding areas near the home are well maintained. The dining room is clean, spacious with ample natural light, which looks out to the front of the home. Low-level light switches and call bell systems are in place to ensure the safety of residents. Emergency exits are well lit and clear of any obstructions. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 19 The Inspector observed residents moving around the home, choosing to sit in their preferred lounge or going to their bedroom. Residents were seen using the passenger lift independently and walking using their walking aids. The Inspector viewed two resident’s bedrooms (with consent), which were clean and spacious. The bedrooms were personalised to some extent with personal belongings, as residents were at Brookside Court only for a short stay. Residents felt they had sufficient private space to store their walking aids and for the use of the hoist. Bathrooms and toilets were clean and equipped with specialist equipment for the moving and handling of residents and a supply of protective clothing such as gloves, aprons and antibacterial gels. The home has a range of specialist equipment to assist residents on a daily basis during their stay and for rehabilitation. This included electric hospital beds, hoists, mobility and other specialist aids to assist with rehabilitation. The therapy room was equipped to aid resident’s rehabilitation. There is a domestic kitchenette used by Occupational therapist with residents undergoing their rehabilitation. Domestic staff were seen cleaning resident’s bedrooms. Care staff spoken with demonstrated a good understanding and knowledge of their responsibilities to prevent the spread of infection and health and safety guidelines. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained and qualified staff are employed following robust recruitment checks and employed in sufficient numbers, with the use of agency staff to meet the needs of the residents. EVIDENCE: On the day of the site visit the care and ancillary staff on duty was as per the staff rota. The Assistant Manager said regular agency staff continue to be used to make up a full staffing compliment. Agency care staff said they were familiar with the residents and the procedures in the home. Care staff spoken with felt whilst agency care staff assist with residents and the daily tasks in the home, the home would benefit from having permanent staff. Care staff and therapists said they work well together, sharing information and communicating issues promptly, to benefit the residents receiving rehabilitation. The local authority’s recruitment procedure is robust, which is managed by the Human Resource Team. The information received from the Registered Manager, (now retired) showed staff had satisfactory pre-employment checks including Criminal Records Bureau (CRB) and references. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 21 Staff spoken with described the recruitment process, which was consistent with the local authority recruitment procedure and the induction training received. The Inspector examined four care staff’s file, which contained confirmation of the completed induction training and job specific training. Staff files had records of the supervision meetings, which was confirmed by the care staff. Minutes of the staff meetings are produced timely and available to staff unable to attend. The Assistant Manager confirmed that 81 of the care staff had achieved National Vocational Qualification (NVQ) in care level 2 and above and 61 of care staff hold a current first aid certificate. Staff training records showed training completed in moving and handling, safe guarding adults, person centred planning, food hygiene, fire training, infection control training and COSHH (Control of Substances Hazardous to Health). Specialist training completed by care staff ranged from older people, mental health, Parkinson awareness, dementia awareness, stroke awareness, rehabilitation and intermediate care. Care staff demonstrated a good awareness of the residents’ care needs. Care staff described how they support and assist residents to maintain and do the exercises identified by the therapists to regain their skills and confidence. The therapists said care staff are trained by them to follow the rehabilitation programme and promptly report improvements and difficulties. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a sense of leadership and team working, ensuring residents health, safety and welfare are promoted and protected by the home’s procedures. EVIDENCE: Following the retirement of the Registered Manager, an Acting Manager has been appointed. The Acting Manager has achieved the Registered Managers Award. Assistant Manager and staff spoken with said some changes have been made such as teams and supervisory responsibilities. Staff said they were fully aware of their daily duty and responsibilities towards the residents and team working. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 23 Quality assurance was discussed with the Assistant Manager. It was confirmed that the ‘Residents Questionnaire’ has been revised since the last inspection but has not actively been used to seek the views of the residents. There is no other quality assurance system in place. The Assistant Manager did confirm monthly visits take place by a representative of the Responsible Individual, external to Brookside Court. However, no reports generated from the visits were available. After the site visit, the Team Manager who does the monthly visits said no reports are produced. The Team Manager gave assurance that reports would be produced following the monthly visits and made available at the home. ‘Residents’ meetings’ are held every three-months and residents can choose to attend. The minutes of the meeting were made available and showed the topics discussed at the last meeting included the complaints procedure; residents rights to look at their records; fire procedure; meals and noted the comments received from the residents, “hard work done by the staff”. Residents have keys to their bedrooms. A lockable cash tin is provided in each bedroom for residents to safely keep money. Alternatively, residents can have their money stored safely in the office and cash records maintained, thus indicating procedures are in place. The residents said they preferred to look after their own money, some with the help of their relatives. Staff said they receive supervision with their line manager and have monthly team meetings. There are joint meetings held with the therapists on a weekly basis, primarily to discuss the progress of residents receiving rehabilitation. Staff files contained supervision records. The minutes of the last team meeting viewed, covered topics such as meals, staffing, Christmas. Risk assessments carried out with residents for mobility, falls, rehabilitation and the measures were reflected the their care plans. The therapists for residents undergoing a programme of rehabilitation carry out detailed assessment of risks. The care plans produced by the therapists are kept in the resident’s bedrooms to encourage residents to follow with some assistance from the care staff. Residents said they felt safe both in the home and with the care staff looking after them. From the discussion with the care staff, training and care records viewed and observations made indicated staff followed safe practices. The Pre Inspection Questionnaire received by CSCI before the site visit detailed the regular maintenance of health and safety systems in the home such as equipment, fire, central heating and emergency call bell systems. Records randomly checked indicated fire drills and alarm tests are carried out regularly. The accident book was consisted with the notifications sent to the CSCI detailing events that have affected the residents’ safety and wellbeing. Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 24 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 3 X 4 X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 4 X 3 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 3 X 3 Brookside Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action 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 Court DS0000037671.V326044.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Area Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brookside Court DS0000037671.V326044.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. 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