Inspection on 06/03/06 for Brookthorpe Hall Care Centre

This inspection was carried out on 6th March 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brookthorpe Hall Care Centre 07/04/09

Brookthorpe Hall Care Centre 21/04/08

Brookthorpe Hall Care Centre 14/12/06

Brookthorpe Hall Care Centre 05/09/05

Brookthorpe Hall Care Centre 13/01/05

Brookthorpe Hall Care Centre 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

Fairfields Country Rest Home

St George`s

5 Seafield Road

Credence House

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Brookthorpe Hall Care Centre Stroud Road Brookthorpe Glos GL4 0UN Lead Inspector Mrs Janice Patrick Unannounced Inspection 09:30 6 March 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 Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brookthorpe Hall Care Centre Address Stroud Road Brookthorpe Glos GL4 0UN 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) 01452 813240 01452814394 j.arnman@brookthorpe.com Frampton Residential Homes Limited Miss Michaela Chandler Care Home 32 Category(ies) of Learning disability (2), Old age, not falling registration, with number within any other category (30) of places Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two beds can be used for service users under the age of 65 years of age. That service users under 65 years of age must be over 50 years of age. 9th June 2005 Date of last inspection Brief Description of the Service: Brookthorpe Hall is a nineteenth century building that has been sensitively adapted for its stated purpose. It is registered to provide personal care for 30 older people, with an additional category for two people with a learning disability. This Care Home therefore does not provide nursing care. The home is very spacious and provides easy access with a staircase and shaft lift accessing all four floors. Communal lounges and a dining room are situated on the ground floor and residents’ private accommodation is located over three floors.The home uses contracted caterers offering a good degree of choice of meals for residents. The home has an activities co-ordinator and provides varied optional opportunities for social activity and interest. This home aims to meet the National Minimum Standards (NMS) for Older Persons and meets with requirements from other statutory agancy’s such as the Fire Department and Environmental Health Department. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two Inspectors between the hours of 10.00am and 12.50pm on the first day and 10.25am and 1.25pm on the second day. The Registered Manager and Deputy Manager were on duty each day as were other members of the home team. The Registered Proprietors were available for the duration of the second day. A total of 22 standards were inspected which included the following areas: • The homes process of pre admission assessment and ongoing assessment processes • Care planning, general care documentation and involvement of outside health professionals • How the staff maintain residents privacy and dignity • Residents ability to make choices • Family and friends visiting • Food and dining environment and related records • Complaint processes and related records • How the home protect the residents against harm and abuse • The cleanliness of the home and general infection control practice • Staffing and related records • Staff training and development and related records • The management style and structure • Quality Assurance • Residents personal monies • Staff supervision and related records • General health and safety practice and related records Several residents were spoken with to ascertain their views on the care and services provided. Two relatives were also spoken to for the same reason. One visiting health care professional was spoken with to gain her opinion of the care provided. The management staff and care staff were spoken with throughout the inspection and were helpful and co-operative. Feed back on the inspection findings were given on completion and were received in a constructive and positive way by the Registered Proprietor. What the service does well: Residents and relatives are clearly very happy with the care provided and said the home has a friendly atmosphere. Generally a good standard of care documentation is maintained, but some care plans need to be more specific to the resident’s assessed needs. Staff are trained and supervised well. A good standard of food is provided in a pleasant dining room. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 6 The communal rooms and some bedrooms offer widespread views across the countryside. 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. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 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 Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 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&6 The assessment process used in this home ensures that staff are aware of a new resident’s needs prior to admission, but a lack of the process when readmitting a resident who has regular respite care may lead to needs having changed and not being identified before re-admission. This home does not provide intermediate care. EVIDENCE: Examples were seen of 3 resident’s pre admission assessments. The Registered Manager confirmed that all residents are assessed prior to moving into the home. Another member of staff explained that the pre admission information is kept within a file that is prepared for the prospective admission and that senior staff usually inform care staff of the individuals needs. One member of staff was heard explaining to an enquirer that the home could not accept their enquiry, as the individual required ‘nursing care’ and the home was registered for personal care only. The care records of one resident admitted for a period of respite recently only had documentation relating to an admission in August of last year. Although a Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 9 record of daily events was being maintained, an assessment of needs had not been carried out prior to this admission. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 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, 8 & 10 Care planning is generally well maintained and gives staff clear guidance in how to meet the residents’ needs, although in one case assessed needs did not have a related care plan. Arrangements are in place to ensure residents have access to all external health care agency’s needed to help meet their health care needs. Personal support in this home is offered in such a way so as to promote the residents’ privacy and dignity, although two toilets with missing locks would compromise this. EVIDENCE: The care documentation for 5 residents was inspected. Care plans were relevant and generally reviewed monthly. One resident had several needs that had been identified within an assessment of needs but these were not reflected within the written care plans for this person. The care documentation also contained other assessments such as oral assessments, moving and handling assessments and assessments relating to potential pressure ulcers. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 11 A Community Nurse who visits the home several times a week thought that the home offered a good standard of care, but that staff needed reminding sometimes to place pressure-relieving cushions under residents. Apart from this she was confident that staff followed the instructions left for them. Records showed that a Consultant Psycho geriatrician had reviewed a resident within the last 3 months. The Continence Nurse Advisor is also a regular link to the home, along with a chiropodist and the GP. One resident explained that the wheelchair she was sitting in was her own and she had gone through a process of special fittings for it. Two relatives confirmed that their relative had been at the home now for 7 years and they had just attended a joint review of her care with her Social Worker. Most of the residents spoken with were able to confirm that staff carried out tasks in private and spoke to them in a manner they would choose to be spoken to. The two relatives who said they visit at different times of the day also confirmed this. It was noted that two main toilets did not have locks on them. The Registered Proprietor explained that a lock was missing altogether because a resident had locked herself in the toilet the week before and this was removed in order to get her out. And the second toilet did not have a lock because staff tended to escort residents to this toilet and stay outside for the duration of its use. One resident was observed to use this toilet independently and would not have had the option of locking it. A third toilet was seen to have a lock. Shared accommodation had appropriate curtains to screen individual beds. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Arrangements are in place to help residents make choices on a daily basis pertaining to recreational choices, what they eat, who visits them whether they wish to socialise or not. EVIDENCE: One resident spoken with confirmed that she was able to make a choice about whether she joined in with the activities or not. A list of who had which newspaper was seen and this resident confirmed that she received two a day. Another resident said they always joined in what ever was happening. A quiz was held on one of the mornings and this resident was observed to be very quick with the answers. It was noted that at least half of the residents in the room were asleep during this, which was just before lunch. A member of the care staff sat between two very frail residents during this time. One resident who was joining in, was sitting in a wheelchair facing away from the activities co-ordinator. On another occasion several ladies and the co-ordinator had got together to knit. Booked entertainment was listed on the notice board. The Registered Manager confirmed that the activities co-ordinator also sees some residents on a one to one basis. Another resident who remained in her bedroom and who was blind and virtually deaf said she did get very bored. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 13 Another resident said she was now resigned to the fact that she had to stay in her room. She had severe problems with her posture, which made it difficult for her to sit in a normal chair and hold her head up. Staff explained that she has said she prefers to remain in her bedroom, although it was noted that there was no way for her to get downstairs anyway as she was between flights of stairs and would clearly be unable to use the stair lift. This resident did say that she did not mind her own company. It was noted that many residents in the communal rooms remained in a wheelchair for most of both mornings. The Inspectors wondered if this had been their choice, many were unable to say. Visitors are obviously welcomed. This was confirmed by two visitors and by the residents. One resident confirmed that she saw her priest weekly. Lunchtime was observed. The dining room was attractively set and staff sat alongside residents who required help. A drink was available for each resident. One resident said the food was lovely. Another said it was his favourite on Friday’s, Fish and Chips. Trays of food were taken to those who chose to eat in their bedroom. One resident had her food some distance from her when visited by the Inspectors in her bedroom, but was managing. One resident who remains in her room said the food was nice but it was noted there was no drink. Another resident also agreed the food was good and she particularly liked the juice served at breakfast. She also confirmed that she could be a fussy eater, but the staff knew her well. Contractors on site cook the food and menus rotate every four weeks. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 14 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 There are arrangements in this home to ensure that people know how to make a complaint and to feel reassured that their complaint will be adequately dealt with. The home actively sets out to protect vulnerable residents, although further training for staff maybe required so that staff are fully confident about the process to take in the event of an abusive situation. EVIDENCE: The complaints procedure was on the office notice board and the main notice board of the home. Visitors and some residents would be able to see this. A member of staff was aware that any complaint made was recorded and investigated, although the complaint file could not be found in the office at this time. Residents spoken to felt they would each know who to go to if they had a concern/complaint and confirmed that the Manager was very approachable. The same member of staff was asked how she would deal with an allegation of abuse whilst in charge of the home. She was obviously aware that she would need to contact the Manager or the Proprietor, but was unsure of the actual action she would need to take as the person in charge of the home at that moment. She was aware that a policy on this subject existed but was not sure of its contents. This may require further clarification within the home. Additional training can now be sourced, which will enable the home to be aware of the county’s protocol on abuse and adult protection processes and help them ensure that their policy falls in line with this. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 15 One of the domestic staff was also spoken to on this subject. She said that she speaks to many residents in the course of her days work and confirmed that she would report anything to a senior member of staff that gave her concern. She had worked at the home for a number of years and said that she has never witnessed staff be unkind and spoke of a zero tolerance of any such behaviour. All residents spoken to said they felt safe and well treated and two relatives who have been visiting for a long period of time said they had never witnessed any staff ill treating or speaking to residents in a way that would make them feel uncomfortable or concerned. Staff who undertake their NVQ training in care, cover the topic of abuse and adult protection, although it was noted that further training in abuse was being organised. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 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): 21 & 26 There are ample communal toilets and bathrooms as well as private facilities for resident use although residents on the mezzanine floor do not have access to a bathroom if they are immobile. Although the home has several procedures relating to infection control and maintaining cleanliness there were several practices seen that would question whether staff are following these guidelines. EVIDENCE: The home has several toilets and bathrooms for resident use, although the top floor bathroom was being used for storage. One resident spoken to said she did not have a bath as she has become immobile and unable to use the stair lift. The shaft lift does not access this mezzanine floor. The resident said however, that she would find having a bath difficult and was happy with the strip wash given. The Registered Proprietor explained that the resident did not wish to move rooms. Some bedrooms have a toilet area that has been incorporated behind doors within their bedroom. All bedrooms have wash hand basins. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 17 Some staff have received training on infection control and basic hygiene and others are booked in as seen on the home’s training matrix and which was confirmed by the Registered Proprietor. At lunch time staff were seen wearing colour coded plastic aprons when serving. However, a faeces soiled chair cushion was found in a bedroom, one bed had been made and was not clean, another was debateable as to whether it was soiled with food or faeces and an overnight catheter bag was seen in a sluice area with the connection tube uncovered on the floor. The domestic was seen cleaning various toilet floors but the water and mop head was black. These areas were pointed out to the Registered Proprietor who was concerned to hear this and who will investigate current practice. Two residents were spoken with mid morning and had food debris around their faces; these were residents who would have required some help with their feeding. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 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, 28, 29 & 30 Staff receive training and work in enough numbers to meet the current needs of the residents, but an audit of night falls would help to ensure that the deployment of staff was correct. Arrangements are in place to ensure there is good recruitment practice so as to help protect vulnerable residents. EVIDENCE: At the time of this inspection there were 6 vacancies. Staffing therefore consisted of 3 care staff and the activities co-ordinator. Although the Registered Manager was one of the included care staff on duty, she confirmed that this was adequate staffing. There are 3 care staff in the afternoon and two waking staff at night. An added complication for the home during the week of this inspection and had been for a couple of weeks previously was the absence of the administrator. This meant that staff were having to answer the telephone. On the second day of the inspection, one of the Registered Proprietors was carrying out administration work. Both Registered Proprietors are actively involved within the home performing many tasks such as maintenance and organising the training department. The home is an accredited training centre and therefore there is a great enthusiasm for good staff training. The majority of the staff either hold an NVQ Award or are in the process of achieving this. One carer, who had worked in another establishment prior to this one explained that it was an expectation at Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 19 this home that staff would undertake the NVQ Award in Care. She and several other staff commented that the Registered Manager and the Deputy Manager were very supportive in this area. Induction training records were seen, including evidence to show that other training is provided. Good practice was identified in the area of medication. Only staff that hold an accredited training administer medicines. However, one member of staff that had been working in the home since July 2005 had not received fire training or moving and handling training in this home, but said she was up to date from her previous employer. Consideration should be given to all staff being trained in all mandatory subjects once they start employment at Brookthorpe Hall Care Centre, despite holding training records from another establishment. This is especially important where fire training is concerned, as the layout of the building would be different. Recruitment files were inspected. These were not overly organised within the file itself but contained all the criteria as required within the Care Home Regulations 2001 except the absence of one photograph. Other documentation required from the Home Office for overseas staff was also present. This home does not have a fast turn over of staff. All staff commented that it was a friendly and supportive team. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 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, 33, 35, 36 & 38 The Home is managed by a person competent to do so who runs the home for the benefit of its residents. Although the views of the residents are ascertained, it would be fair to say that the quality assurance system needs to expand and mature into a system that clearly demonstrates how standards and services are improved upon. The home does not take any responsibility for residents’ personal monies. Arrangements are in place to demonstrate that care staff receive adequate supervision to ensure they are carrying out their job correctly and well, this now needs to include all staff employed in the home. Residents live in a home that generally adheres to good health and safety practices, although the consistent lack of footplate use when transporting residents in a wheelchair is very poor practice. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 21 EVIDENCE: The Registered Manager is clearly popular and supportive to residents and staff. She holds all the required qualifications in management and care practice and is also a NVQ Assessor. The Deputy Manager in turn supports her along with senior care staff. Residents commented that they find both very approachable, including the two relatives spoken to during this inspection. The Registered Proprietor explained that the views of the residents are sought on a regular basis. Several residents commented that they are quite often asked their views on various things in the home, be it the food or what activity they particularly like or would like to help plan. A comment book sits in the reception area but has not been entered in. It was explained that consideration should be given to broaden the home’s auditing processes in order to help with the preparation for the future requirement by the CSCI of an Annual Quality Assurance Assessment. During this inspection it was noted that 25 falls had been recorded since the 2/10/05 to date and that 16 of these had been during the night shift hours. The job guidance seen on the office notice board for night staff appeared to incorporate a lot of domestic chores. Consideration should be given to carrying out an audit on the number of falls, the time and type of fall and exploring why there are so many more falls at night and how these can be reduced. The Registered Proprietor explained that the home does not take any responsibility for the safe keeping of personal monies, although each bedroom is provided with a lockable drawer. All monies are dealt with through a Power of Attorney arrangement or the resident has their own informal agreement with their family. Records of care staff receiving supervision were seen; this system is soon to include non-care staff. All health and safety records were inspected. These included weekly fire system checks, last recorded entry 27/01/06. Visual checks on fire fighting equipment are carried out and records dating back to 2004 were seen. Fire drills are carried out with staff and the last drill was 7/2/06; seven signatures were seen as attending this, two were night staff. It was noted that one member of the night staff team had no record of fire training since the beginning of the present record which commenced in 2004. This was pointed out to the Registered Proprietor who will investigate. Consideration should be given to the storage of a recliner chair at the top of a fire escape stairs and the type of cupboard/situation of cupboard that cannot be closed on the top floor, used for storing linen. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 22 Various risk assessments were seen during the inspection. Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X 3 X X X X 1 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 2 X 3 3 X 1 Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) (a&b) Requirement The Registered Manager must not offer accommodation to a service user unless the needs of that person have been fully assessed by a person competent to do so. The Registered Manager must ensure that a written care plan is devised for all assessed care needs. The Registered Manager must ensure the practices within the home aid the service users privacy and dignity at all times. The Registered Manager must be able to provide social activities for those that severe sensory deprivation. The Registered Manager must ensure that training and any other arrangement within the home that is designed to protect service users from harm/abuse is fully understood by all staff. The Registered Manager must ensure that arrangements made in the home to prevent the spread of infection and aid good hygiene are followed. DS0000016392.V276988.R01.S.doc Timescale for action 26/05/06 2. OP7 15(1) 26/05/06 3. OP10 12(4)(a) 26/05/06 4. OP12 16(2)(n) 26/05/06 5. OP18 13(6) 26/05/06 6. OP26 13(3) 26/05/06 Brookthorpe Hall Care Centre Version 5.1 Page 25 7. OP33 24(1) (a&b) 8. 9. OP36 OP38 18(2) 17 Schedule 4(6g) 10. OP38 13(5) The Registered Manager must devise a system that helps not only ascertain views from service users on the home’s services, but that helps the home identify where improvements to care and services can be made and which is able to measure any action taken. The Registered Manager must be able to demonstrate that all staff receive adequate supervision. The Registered Manager must ensure that each member of staff is able to demonstrate that they have received Fire training and Moving and Handling training. The Registered Manager must ensure that arrangements for moving and handling service users demonstrate safe and best practice. 01/07/06 01/07/06 26/05/06 26/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations All staff who commence employment at the home, despite having undertaken trainings elsewhere should undertake all mandatory trainings as part of their induction programme. An audit should be carried out into the falls within the home at night and deployment of night staff tasks reviewed to ensure the needs of the service users are being adequately met. The recliner chair at the top of a fire escape route and the storage of linen on the top floor should be reviewed and reconsidered in relation to fire safety. 2. OP33 3. OP38 Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Brookthorpe Hall Care Centre DS0000016392.V276988.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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