Inspection on 03/08/06 for Brookvale

This inspection was carried out on 3rd August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brookvale 21/01/06

Brookvale 23/05/05

Brookvale 01/02/05

Brookvale 01/09/04

Brookvale 22/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Brookvale 167 Simister Lane Prestwich Manchester M25 2SF Lead Inspector Lucy Burgess Unannounced Inspection 3rd August 2006 11:00a Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookvale Address 167 Simister Lane Prestwich Manchester M25 2SF 0161 653 1767 0161 655 3635 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) Brookvale Mrs Lynne Richmond Care Home 74 Category(ies) of Learning disability (74) registration, with number of places Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home is registered for a maximum of 74 service users who are in the category Learning Disability (LD) That within the overall number: • 3 Southview Terrace, Simister Lane, is used to accommodate no more than 3 service users. • 1 Southview Terrace, Simister Lane is used to accommodate no more than 3 service users. • 2 Southview Terrace, Simister Lane is used to accommodate no more than 3 service users. • 4 Southview Terrace, Simister Lane is used to accommodate no more than 3 service users. • 357 Heywood Road, is used to accommodate no more than 4 service users. • The Atrium, is used to accommodate no more than 14 service users. That the service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 21st January 2006 3. Date of last inspection Brief Description of the Service: Brookvale is a purpose built establishment registered to accommodate 74 younger adults with a Learning Disability. It is a Charitable Trust, which seeks to cater for Jewish people although non-Jewish service users are also accommodated. Permanent, and respite care is offered together with day care. The range of fees vary from £500 to £1000, dependent on assessed needs. The majority of the home provides ground floor accommodation. One wing is on the first floor level. In addition to the main building, there is South View, four cottages each accommodating the more independent service users, a larger house approximately 1 mile from Brookvale, which can accommodates 4 service users and the Atrium. This provides spacious accommodation for up to 14 individuals each with single en-suite bathrooms. A few individuals through their own choice share rooms. The homes facilities include an indoor hydrotherapy/swimming pool, fully equipped gymnasium, music therapy centre, computer room and a sensory light and sound room. There are extensive, well-maintained gardens, which are easily accessible to all service users. This includes a cycle path and crazy golf pitch. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day by two inspectors. The inspectors spent time looking round the home, viewing records as well as talking with residents and staff. Discussion and feedback was also held with the Manager. The home is registered to provide accommodation for up to 74 people. At the time of the visit there were 64 residents at the home. Although the inspection was unannounced the completion of a pre-inspection questionnaire was requested, along with feedback surveys from residents, relatives and health professionals who are involved with residents. The inspector received 20 completed surveys. These were from 16 residents, 3 relatives and 1 health professional. Comments have been added to the report. All the key standards were looked at during this inspection visits. What the service does well: What has improved since the last inspection? Work has been carried both inside and outside of the home. A new toilet and shower room has been built near to the day centre. This provides fully adapted equipment to meet the physical needs of residents. Outside of the home there has also been work undertaken to the large rear garden with a crazy golf course, cycle path and garden furniture where residents were seen relaxing with each other. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 6 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. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system of assessing prospective residents prior to admission to the home gives an assurance that a resident is only admitted if the home is able to meet their needs. EVIDENCE: Since the last inspection there have been four new permanent placements as well as planned short-term arrangements. Prior to new service users moving into the home either on a short-term or permanent basis, information is requested from the funding authority as well as any other health and social care professionals who may be involved with the care and support required. Opportunity is also made available for service users and their families to visit the home or for staff to visit prospective residents so that additional information can be gathered. For example, two of the managers visited a prospective resident who had been referred to the home as they wished to gather more information based on what needs had been identified within the assessment information provided. This enabled them to make a more informed decision about whether the placement was suitable. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 9 Once a placement is agreed, observations are made by the staff in relation t how the individual is settling into the home, their routine and preferred activities. Information is gathered within the first 6 to 8 weeks and then a formal review is held to establish the suitability of the placement. One of the files was examined for a new resident. Pre-admission information included a community care assessment from the funding authority. The initial information was 5 years old however it been up dated to reflect current circumstances, health care needs, behaviour and significant events. This information along with observations made by staff is used to develop the care plan. Although Brookvale is a Jewish home, they will accept referrals from individuals who are of other faiths/cultures. Prospective residents and families are made aware that the home observes Jewish dietary laws as well as traditional festivals. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information gathered in relation to care and support of residents was not consistent therefore did not provide staff with all the necessary information in relation to meeting the emotional, social and physical needs of the residents. EVIDENCE: Information continues to be held for each of the residents. Files include a care plan, risk assessments, daily timetable, information from other professionals and assessments. Additional records are held with regards to daily activities. The primary care unit also holds information with regards to the health and well-being of residents, visits from health professionals, weights and medication. The care files for two of the newest residents were looked at. Information provided within each of the file varied. One contained a lot of information about the resident. This included personal details, information from previous placement, medical information and assessments, key worker notes, care plan, risk assessments, weekly timetable and information regarding family contact. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 11 The second file had very little information available. This provided a copy of the social worker assessment including a more recent update, personal details and an initial plan. The inspector was informed that the home had been observing and monitoring how the resident was settling into the home, information gathered would be used to develop the plan. As the resident had been residing at the home for approximately 6 months this information should have been recorded following the admission along with relevant risk assessments then during the settling period further information could be added or amended to the documents. Previous issues were identified at the last inspection with regards to the risk assessments for those individuals with additional support needs due to their mobility or behaviour. The home was seeking out the help of someone suitably qualified who could carry out such assessments. Due to difficulties in accessing the appropriate person this area has yet to be addressed. Further advice was provided with regards to who should be contacted. Each of the residents living at the home has a review meeting. The home has an admissions and reviewing officer who will spend time with residents. It is her role to ensure that information is gathered for the initial 6 to 8 week review following placement and then on an annual basis. All relevant parties involved with the resident are invited, parents, family members, social workers, other professional and staff from the home. Minutes are recorded and held on file. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Various activities continue to be offered within the home enabling residents to learn new skills. Residents are also able to access the local and wider community, pursuing leisure activities, developing social skills, follow their culture/religion as well as maintaining relationships with family and friends. EVIDENCE: A wide variety of activities are provided within the home. Each of the residents has a planned weekly timetable, which includes activities provided within the day centre provision at the home. However those who did not wish to participate within the group activities preferring their own routine are able to do so. Some of the more able residents continue to have small jobs within the home helping staff in the kitchen or the handyman. Some of the activities provided include; keep fit, swimming, cookery classes, music classes, aqua aerobics, yoga, and massage and beauty therapy. The home also has an arts and crafts worker who visits the home once a week Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 13 providing sessions in arts and crafts. From observations made the group is well attended. Residents were also seen to be enjoying the gardens available within the home. Due to the good weather they were able to walk round or sit and relax in the well maintained gardens. A number of residents continue to attend synagogue either with family or with other residents from the home. Residents at the home were also looking forward to the ‘Olympics day’, which was taking place later in the month. Residents participate in group and individual events. Friends and family are also invited. One of the managers also said that a hiking club was being set up, with a recent walk taking place in the Lake District. Other staff were being encouraged to become involved so that day trips could be arranged. Discussion was held again with the reviewing officer with regards to exploring outside support employment for some of the residents, several of who previously had jobs away from the home enabling them to develop other relationships as well as increase their independence. Residents also have free time where they are able to relax spending time in the communal lounges or in their own bedrooms watching television, playing DVDs and CDs etc. Others chose to go shopping, for a walk, watch football or ride their bikes. Some of the residents live in separate accommodation close to Brookvale and receive less staff support. Individuals have bus passes and access the local and wider communities independently. Two of the residents have recently bought bikes, which they use to cycle to and from Brookvale from their home, which is approximately a mile away. Residents continue to have regular visits with family and friends with visits taking place both at and way from the home. Some of the residents spend each weekend with parent or family. Where necessary transport is provided to take someone to and from home/visits. Feedback was received from family members within the surveys. Comments included; the residents ‘enjoy a quality life, which would difficult to provide elsewhere’ and ‘we’re grateful for the overall family environment’. The home has also recently purchased a holiday home in Lytham St Anne’s after selling their previous home in Wales. Arrangements are to be made for residents to have a small group holiday. Consideration is also being given for some residents to take a holiday abroad later in the year. In relation to meals, the food continues to be prepared by designated kitchen staff with some residents helping with small tasks including preparing food, setting table and clearing the dining room. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 14 All meals are kosher and observance is maintained over Shabbat. Breakfast, lunch and the evening meals are each served over a two hour period allowing for the number of residents as well as their routines. Those residents with particular dietary needs and requiring assistance from staff are supported in a separate dining room. Additional food is prepared for supper, this includes sandwiches or snacks. Comments received from residents included; ‘I get nice meals’, ‘I think Brookvale is a marvellous place to live’, ‘at weekends I go out with my friends or I go home’, ‘at Brookvale there’s lots to do’ and ‘l like the food here, going swimming and I like cooking sometimes’. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs are consistently met ensuring their well-being is maintained. The medication system is clearly managed and audited however records need to be completed in full ensuring residents are protected and practice is safe. EVIDENCE: All records and information with regards to the health and welfare of residents is held within the primary care office. This includes records of visits from the GP, dentist, district nurse, chiropodist, hygienist etc. Whilst domiciliary visits are made to the home a number of residents will visit the local surgeries. Support is provided where necessary. Feedback from the visiting GP was ‘it’s an excellent home, service users well looked after’. Each of the residents have varying support needs, whilst some are able to address their own personal care needs others are not, requiring prompts, encouragement or physical assistance. The home has previously been assessed and adapted to meet the physical needs of residents. Specialist equipment has been provided in a number of areas within the home to allow for the appropriate level of care to be provided. Equipment includes assisted Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 16 toilets and bathing facilities, ceiling tracking hoists and grab rails. This enable staff to support residents fully and safely. A large number of bedrooms are also available on the ground floor therefore more easily accessible to those residents who have physical support needs. In relation to the safe management of medication. Specific staff members who work within primary care undertake this. The room was found to clean and tidy, information and items were orderly and well managers. The senior member of staff spoken with had a good understanding of the residents needs and in relation to her role and responsibilities. Relevant medication training has previously been undertaken by staff that are responsible for the administration of medication. On examination of the system items were found to be stored safely. Records are made of all items brought into the home as well as those returned to the supplying pharmacist. Periodic audits of the system are also carries out be the pharmacist and feedback provided to the local PCT. Controlled drugs are stored appropriately and double signed by staff on administration. A separate fridge is available for any items, which require refrigeration. On examination of the MAR sheets it was found that some of the records had not been signed following administration. As the sheets are attached to the doset trays, the staff must completed the records when given ensuring practice is safe and accurate records maintained. It is also advised that written records particularly for those individuals receiving short term care are checked and double signed by two members of staff to confirm that the information recorded is correct with the prescription. The Manager is reminded that any accidents, incidents or concerns, which may arise and affect the well-being of residents must be notified to the CSCI in line with the regulation. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place with regards to the protection of service users as well as responding to their concerns. On-going training still needs to be provided ensuring staff are aware of what action to take and the residents are protected. EVIDENCE: As previously identified the home holds policies and procedures in relation to the safety and protection of service users. A copy of the complaints procedure is also accessible to both residents and visitors to the home. A copy of the procedure is also held within residents’ files, which they have in their rooms. No complaints have been received by the home or CSCI since the last inspection. In relation to training, an outstanding requirement remains. Whilst some staff have undertaken training in adult protection the majority have not. This should be addressed. Further information can be found with the report for Beit Yehudit, the children’s service at Brookvale with regards to staff training needs. The home continues to hold additional policies and procedures with regards to adult protection these include resident’s finances, accidents and emergencies, confidentiality and missing persons. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 18 In relation to finances, Brookvale acts as corporate appointee for the residents. Money is held securely in a separate resident bank account. Statements for the account are available for inspection if requested. Those individuals who are able to receive their full personal allowance, lockable storage is available in each residents bedroom for the safekeeping of money and belongings. All transactions are signed for. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Brookvale provides spacious, comfortable accommodation, which is wellmaintained and adapted to meet the needs of the residents. EVIDENCE: Brookvale comprises of North View and West View, which are situated in the main building. South View is a group of 4 cottages at the side of Brookvale, each providing accommodation for 3 residents, the Atrium is a relatively new building providing accommodation for up to 14 residents and finally Heywood Road, which is a detached property approximately a mile from Brookvale which can accommodate up to 4 residents. Each of the buildings are extremely well maintained, as are the gardens, and offer a variety of safe settings. The majority of rooms have en-suite facilities with further bathrooms and communal toilets available throughout the buildings. Several rooms within the Atrium have been identified for respite/short term placements with four rooms having access to ceiling tracking hoists and assisted bathing for those individuals with specific care needs. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 20 Each of the buildings have ground floor level access and are easily accessible to residents in wheelchairs. Sufficient aids and adaptations are provided allowing residents ease of movement around the home. Appropriate checks are also carried out ensuring the health and safety of residents and staff. Furnishings and fittings are of good quality throughout. Further redecoration and refurbishment has taken place within the main building, due to additional provision of toilets and bathing facilities next to the day centre, this provides easy access to both residents and staff and have been equipped to a high standard. The home has a large laundry facility and team of staff who take responsibility for all general and personal items. There are also designated domestic staff that are employed to ensure that the home is kept clean and tidy. It was clearly apparent that the domestic staff continue to maintain the home to a high standard of cleanliness and hygiene. Adequate provisions are available with regards to protective clothing and suitable hand washing facilities to prevent any cross infection. Comments made by residents about the home were, ‘it’s a very nice home’, ‘it’s lovely’ and ‘it’s beautiful’. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All relevant information in relation to the recruitment and selection of staff needs to be gathered to ensure the safety and protection of residents. Training has been identified to equip the staff with the knowledge and skills required in meeting the needs of residents. EVIDENCE: Since the last inspection only 3 new staff had been employed by the home. Each had been recruited using an overseas agency. Information held on file included CV with employment history, references, evidence of previous training, information from the home office and work permits. Criminal record checks had also been sought however whilst these were being processed staff had commenced working at the home. The Manager must ensure that staff do not commence employment until relevant checks have been sought in relation to both adults and children and that information is held on file. Care should also be taken in ensuring that all relevant categories in relation to POVA/POCA have been completed. NVQ training has been provided to staff. In September 2006 a further 12 staff will be enrolling for the course. This will mean that all care staff will have Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 22 either done or be doing the course. Arrangements are also being made for 3 housekeepers to undertaken an NVQ in cleaning and support services whilst 4 kitchen staff will also undertaken training in covering their relevant responsibilities. With regards to training, a number of courses have been made available throughout the year. These have included: • Dementia • Challenging behaviour and physical intervention • Palliative care • First aid • health and safety • moving and handling • epilepsy • risk management • hydrotherapy • person centred planning • activity day – this included exploring age appropriate activities for people with learning disabilities involving the community. Whilst all staff have not attended the above further sessions are to be arranged. Arrangements had been confirmed with regards to fire safety training and first aid; both had been scheduled to take place following the inspection. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is consistent and reliable for the people living there. Systems are in place for the reviewing of the service provision. Action has been identified with regards to providing a safe environment for residents and staff. EVIDENCE: Whilst the Registered Manager is responsible for the day-to-day management of the home she is supported in her role by a number of managers who oversee specific areas of responsibility i.e. training manager, staff manager, day service manager, primary care manager and assessment and reviewing officer etc. The Manager has worked at the home for many years and has completed the relevant training with regards to her role and responsibilities. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 24 In relation to the monitoring of the service, visits are undertaken by the Providers in line with Regulation 26 and reports are completed. Copies of the information are forwarded to the CSCI. Other feedback is sought through the health care reviews of residents, which the admission and reviewing officer will arrange on an annual basis. Residents, family members and social workers etc, are invited to the meetings. The admissions officer also holds regular meeting with residents where further discussion is held. Feedback is also sought from the staff during the periodic team meetings and supervisions. Comments made be staff was positive, individuals felt that the management of the home had changed, individual’s felt there was more inclusion and that they were listened to. In relation to health and safety, in house checks are carried out by the maintenance man who keeps records in relation to fire checks and water temperature. On examination of the water records, reading had been recorded as very high, whilst the system had been serviced in December 2005. The Manager must check with the maintenance staff the information recorded ensuring that it is accurate. Safety certificates are also held with regards to other checks undertaken within the home. For example; the gas system, fire appliances and alarm, emergency lighting, hoist, small appliances and bath hoist. The 5 year electrical check had still not been carried out, this should be addressed ensuring the safety of these who live and work there. As identified earlier within the report the Manager must also ensure that records in relation to notifiable incidents are forwarded to the CSCI. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement That a general care plan is developed at the point of admission providing staff with information about how to meet the identified needs. That risk assessments are completed by a suitably qualified person on those service users who require assistance with moving and handling. (outstanding requirement) That accurate medication records are maintained when administering medication to residents. That adult protection training is completed by all staff employed at the home. (outstanding requirement) That the named staff team receive training in the positive care and control of children and young people. (Outstanding since 01.02.05 Beit Yehudit) That care is taken in ensuring that all relevant categories have been checked within the CRB and staff do not commence their employment until such checks have been received. DS0000008451.V297652.R01.S.doc Timescale for action 30/10/06 2. YA9 13 30/10/06 3. YA20 13 30/10/06 4. YA23 18 30/11/06 5. YA23 18 30/10/06 6. YA34 19 30/10/06 Brookvale Version 5.2 Page 27 7. YA42 23 8. YA42 37 9. YA42 13 That arrangements are made for 30/10/06 an up to date 5-year electrical check to be carried out and a copy of the certificate forwarded to CSCI. (outstanding requirement) That any accidents or incidents 30/10/06 which affect the well-being of residents or the home must been provided in writing to the CSCI. That accurate records are 30/10/06 maintained with regards to water temperatures. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA11 YA20 Good Practice Recommendations That staff consult with a supported employment scheme when reviewing and developing service users daily activities. That written entries to MAR sheets are signed and dated by 2 members of staff ensuring that the information recorded to corrected. Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Brookvale DS0000008451.V297652.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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