Inspection on 31/05/06 for Brookvale Care Home

This inspection was carried out on 31st May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Brookvale Care Home 10/07/09

Brookvale Care Home 09/06/08

Brookvale Care Home 24/09/07

Brookvale Care Home 12/11/05

Brookvale Care Home 13/07/05

Brookvale Care Home 17/12/04

Brookvale Care Home 05/04/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOMES FOR OLDER PEOPLE Brookvale Care Home 111 Warwick Road Olton Solihull West Midlands B92 7HP Lead Inspector Jane Walton Unannounced Inspection 31st May 2006 09:00 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 Brookvale Care Home DS0000004535.V290215.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. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brookvale Care Home Address 111 Warwick Road Olton Solihull West Midlands B92 7HP 0121 706 9097 0121 706 0467 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) Heart Of England Care Mrs Tracey Belinda Arms Care Home 61 Category(ies) of Dementia - over 65 years of age (61), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (61) Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can provide care and accommodation for older people, over 65 years of age who have dementia, mental disorder, excluding learning disabilities. That the home can accommodate two named people, under 65 years of age with dementia. 12th November 2005 Date of last inspection Brief Description of the Service: Brookvale Care Home was built approximately 30 years ago and accommodates up to 61 service users with mild to moderate cognitive deficits and dementia. The home does not offer nursing care. The home is over three floors, each comprising two lounges, dining room and activity areas. There are no ramps as these have been assessed as not required, the home has a passenger lift, and flat access to the garden areas, which are mature with some raised flower beds, there is also an aviary. The home has a full-time activity organiser. The home has a snoozlem installed in the smaller lounge on the ground floor. The home is situated in Olton, Solihull and is close to local amenities, and the local bus services. The home receives visits from the local church, and service users may participate in religious services if they desire. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Inspection took place unannounced over 2 days at the beginning of June 2006. Two inspectors were present on day 1 and one inspector on day 2. The manager of the home was on annual leave, but the newly appointed deputy manager was present, and discussions took place throughout the inspection process. The inspectors were able to speak with 10 residents, 5 members of staff, plus the deputy manager, and 3 formal staff interviews were carried out. The inspector also spoke with 4 relatives who were visiting the home, and a GP who was carrying out a routine visit to residents. A sample of care plans and other records were examined, a medication audit carried out and a tour of the premises was undertaken. What the service does well: What has improved since the last inspection? The overall standard of the residents’ care plans has improved and there was evidence that families are now involved in the production of the care plan. Residents receive appropriate dental care and nutritional assessments are in place. The medication management in the home was vastly improved, and staff have undertaken training in safe handling of medicines. Improvements in the decor of the building were noted, and new bedding and curtains have been provided in many rooms. Areas of the premises that required attention, including the laundry walls and the fitting of a low level alarm in the passenger lift have been addressed. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 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 Care Home DS0000004535.V290215.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 Brookvale Care Home DS0000004535.V290215.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): 1, 3, 4, 5 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. All the practices and procedures surrounding the admission of new residents were adequate and appropriate to ensure that the home is able to fully meet their needs. Prospective residents are provided with sufficient information to enable them to make an informed choice about living in the home. EVIDENCE: The home has a comprehensive statement of purpose and service users guide that provides all relevant information for the resident and their relatives. The manager and senior carers with experience to do so, undertake a pre admission assessment for all prospective residents, to ensure that the home is able to meet their needs. Completed forms, that were very comprehensive, were evidenced in the care plans examined. The home currently provides a range of specialist equipment that includes specialist mattresses, cushions, hoists and assisted bathing facilities. There Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 9 has been some progress towards providing suitable signage in the home for people who have dementia, and there are plans to extend this to all areas throughout the home. Prospective residents and their relatives are invited to visit the home before admission so they are able to make an informed choice as to whether they wish to live there or not, and this was confirmed the relatives of a resident who had been fairly recently admitted. Brookvale Care Home DS0000004535.V290215.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, 9, 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The arrangements for care planning and monitoring physical and emotional health had improved, but a greater attention to detail will ensure that all the residents needs are met. The medicine administration in the home is of an adequate standard, robust auditing will prevent potentially poor outcomes for some residents. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Sampled residents files all had written care plans and risk assessments. Overall, there had been significant improvements in the quality and standard of these plans, they were well written, concise and there was evidence that either the resident or their representative had been involved in the production of the plan and the reviews. One resident had been very recently admitted to the home, and the care plan was not fully completed. The pre admission assessment had identified needs, and basic care management had been addressed. Evidence was seen that the family had been asked if they wished to be involved in the formulation and Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 11 reviews of the care plan, and had signed to say that they did. The social history was not yet completed. Another care plan examined, again identified needs and the instructions of their management was concise. A range of risk assessments had been carried out, but 2 required updating as the residents needs had changed. The changes had been reflected in the current management but not in the risk assessments. A nutritional assessment had been carried out. The stated frequency of blood sugar monitoring was recorded as less than required. The GP had made several visits to see the resident, and has made a referral to a neurologist. Regular visits by the district nurse, optician, dentist and chiropodist were documented. A falls register indicated that the resident had had several falls, and it was recommended to staff that a referral be made to a falls clinic. An activities programme had been devised. The daily records that were examined contained far more detail and were more descriptive of the lives being led by the residents in the home. Conversations with some residents and visitors revealed they had no concerns with the way people were treated in the home, and felt that their privacy and dignity were respected. One relative said that “ my relative is treated with dignity, he has a shower and clean clothes every day. The staff have been very helpful and friendly”. An audit of the medication management in the home was carried out. A Monitored Dosage System (MDS) is used for the majority of medicines, with some individually labelled boxed medicines. A photocopy of the prescriptions is kept with the Medicine Administration Record (MAR) chart for cross referencing purposes. Medicines are kept on all three floors of the home, and the audit was carried out for all. Overall, the recording on the MAR charts was very good with all medicines signed for when received into the home. All medications had been signed for when administered or coded appropriately when they had not been given, except for one gap. Short courses of antibiotics were well recorded. The senior care staff are responsible for the administration of the medication, and all have completed a Safe Handling of Medicines course. The Inspector recommended that the home has a protocol drawn up addressing individual PRN medication needs for two of the residents. Staff must ensure that all creams and ointments are dated on the day that they are opened. Controlled drugs (CD) were stored appropriately and the CD register was completed correctly. Counts of CD stocks were correct. Brookvale Care Home DS0000004535.V290215.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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Residents are supported to maintain social activity, contact and have their recreational needs met. Meals and the mealtimes meet the needs of residents, and the selection of food available helps to promote the residents well-being. EVIDENCE: The home employs an Activities Organiser who works 30 hours per week, and there is a good budget for the provision of activities and equipment. There was evidence that a good range of suitable activities are provided for residents. The care staff are encouraged to be involved to help with continuity when the organiser is not on duty. It was recommended that the keyworkers involved the families and try to obtain more details of residents backgrounds and previous interests. Also the Organiser may benefit from further specific training in activities for people with a dementia. There was information in the care plans sampled to indicate that an activities programme had been produced for the residents. Visitors and families are welcomed to the home at any reasonable hour, and residents are enabled to go out into the community, when accompanied, and if appropriate, to visit such places as the British Legion Club. One resident confirmed that one of the carers accompanies him to the shops and to the public library. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 13 Residents are enabled to exercise choice where they are able, and there was evidence that personal possessions are brought into the home, to enhance the homeliness of their bedrooms. The inspector joined the residents on Garden View for lunch in the dining room. Some attempts have been made to more clearly signpost the dining room, however, they are only temporary signs, and some residents remove them. Plans are to provide a more permanent solution. The dining room is large enough to accommodate the residents of this unit, and allow staff to circulate in the room to assist residents. Tables were laid with cloths, and serviettes were provided, together with plastic cups for the orange or blackcurrant squash provided. There were no condiments on the tables, and these were not offered to residents. People were offered a choice of meal at the table of either beef stew and dumplings or cod in a cheese sauce, with fresh vegetable, broccoli, swede and mashed potatoes. One resident refused any food, and the carer came back again several minutes later and a meal was accepted. The meal served was home cooked, hot and tasty, and reflected the menu that was displayed. A dessert of home made sultana sponge and custard was available. Assistance was offered by the three carers in attendance when it was required. Staff demonstrated a good understanding of the residents likes and dislikes. The residents were observed to enjoy their meal in a relatively relaxed atmosphere. However, it was recommended that the volume of the music playing should be kept at a lower volume, as it can be distracting. Brookvale Care Home DS0000004535.V290215.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 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that is accessible to residents and visitors so that they are aware of how to make a complaint ensuring the promotion of protection matters. EVIDENCE: There is a complaints policy and procedure in place in the home. The current practice is for any “niggles” to be logged in the individual residents file, however, auditing would be facilitated by using a dedicated complaint/Niggles log. The manager has demonstrated that an appropriate Adult Protection policy and procedure is implemented in the home. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Overall, the standard of the environment within this home is adequate, and some improvements have been made to redecorate appropriately. However, further work is required in order to provide residents with an attractive, appropriate and safe place to live. EVIDENCE: A tour of the premises and garden was undertaken. The home has three floors, Garden View (ground floor), Elmdon Unit (first floor) and Aspen Unit (second floor) with residents bedrooms on all. The main dining room is on the ground floor, but each of the other two units has a dining room and lounge/diner. The sitting room on Garden View has recently been enlarged, by removing a part partition wall, and this has improved the available space, and is more homely. Lounge areas are also provided on Elmdon and Aspen Units. The lounge on Elmdon Unit has been newly redecorated, a resident commented she thought it was nice. At the time of inspection quiet music was playing in the background of this lounge, and there was a relaxed atmosphere prevailing. There is a small Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 16 sitting room/library on Aspen unit, where some of the residents were sitting as it was nice and peaceful. There are sufficient toilets and assisted bathing facilities given the current resident category/groups needs. Should this situation change, the owners will need to give thought to providing additional bathrooms at that point. The doors of the toilets and bathrooms have been painted a bright colour to assist the residents with recognition. Discussions are underway in order to improve the signage so as to be more appropriate for people with a dementia, and one option is to have individual “themes” for each floor. Improvements have been made to bedrooms with some being redecorated, and new bedlinen and curtains have been provided. Residents personal items were evidenced in the bedrooms inspected. There is a Snoozelum room on the ground floor, that is kept locked when not in use. In one of the bedrooms on Garden View it was noted that the radiator cover was broken and the fixing to secure the wardrobe to the wall was also broken. Another radiator cover was seen to be broken, near the stairs on the ground floor. It was also noted that the doors to the linen cupboards on the ground and first floors were not locked as had been required by the fire officer on their recent inspection. One of the visitors spoken to was complementary about the standard of cleanliness in the home, and the standards maintained by the housekeeping staff. This was confirmed by the inspector of all the areas seen during the inspection. There is well maintained garden for the residents to enjoy, with lawns and raised beds, together with patio furniture for sitting out. The work in the laundry has been completed as required following the last inspection. The laundry for residents is carried out by dedicated laundry staff who take pride in the appearance of the clothing they deal with for the residents. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. Overall the arrangements for staffing the home are sufficient to meet the current needs of the residents, to ensure health and wellbeing. Overall the recruitment procedure protects the residents. Further staff trained to NVQ2 would ensure more consistent care being delivered to residents. EVIDENCE: The three units in the home are staffed separately, and the rotas indicate that a senior care and 3 carers are planned to be on duty each day on each unit. The manager and deputy are supernumerary. At night there is a carer on each floor and a senior carer on duty to supervise. The home also employs a large number of ancillary staff, including maintenance, housekeeping and laundry staff. The kitchen is also well staffed. Shortfalls in staffing levels are covered either by Bank or agency staff. However, fewer agency staff have been required as several new members of staff have been employed. On the day of the inspection, the manager was on annual leave, and the newly appointed deputy was in charge. However, she was also rostered as the senior on the first floor, so in effect the floor was short of one senior carer. On one of the floors an agency nurse, when asked by an inspector for a care plan, was unsure where they were kept, and not able to advise on how an individual resident was to be cared for. The manager must ensure that all agency staff have a knowledge of the residents needs as detailed in the care plan. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 18 There are currently 57 of the care staff who are trained to NVQ2, which is just slightly over the required number. There is a full time training officer employed by the Heart of England Care who provides a comprehensive range of training for the three homes in the group in Birmingham. The training manager was occupied in training courses during the inspection so was not available to speak to, however, staff spoken to confirmed that they had undertaken training in various areas, including the statutory moving and handling and health and safety. Training in understanding dementia and care is also given. Individual records of training were evidenced in the individual staff files. A sample of the staff files were examined and overall a generally robust recruitment procedure was evidenced. However, the manager must ensure that all files have an up to date photograph, and that all gaps in a persons’ employment record are explored at interview. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 19 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): 32, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service. The home has improved systems for consultation with residents where their views are sought. Extending this to include the views of families, and other health professionals will ensure that the home monitors the standard of the care delivered. The management style of the home engenders an open and inclusive atmosphere The homes’ generally improved standard of record keeping safeguards the residents’ rights and best interests. The generally good standard of attention to the health and safety issues for staff and residents helps promote and protect their health and welfare. EVIDENCE: The manager of the home was on leave at the time of the inspection, so the inspector was not able to meet her. However, there have been several Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 20 improvements evidenced in the home. A newly appointed deputy manager was present throughout the inspection process, and was the first time she had been so actively involved in an inspection. There was a marked calmness in the atmosphere in the home, and residents appeared quite relaxed. The activity organiser holds residents meetings to try and obtain their views and feedback about the home. Staff meetings are also held and documented. However, there is currently no formal Quality Assurance system in place, although the managers of all three Birmingham homes in the Heart of England Care group are currently looking to develop one. The importance of a formal system is recognised. Some staff supervision records were evidenced, however, not all files sampled had a record. The home manages the personal allowance expenditure for the residents. Only small amounts are kept in the homes safe. Staff need to archive some of the previous years’ receipts, to facilitate an audit of the accounts. Also receipts should be numbered sequentially. One of the accounts seen had an incorrect balance, and some receipts were missing. Records of service, tests and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, fire and hoists are well maintained. Most are completed in a timely fashion to promote health and safety. A fire officers visit in February 2006 required that the linen cupboard doors should be kept locked, but on the tour of the premises, they were found to be unlocked, and in one case, the door wide open. It was unclear whether the PAT testing was up to date, as some plugs were labelled ”do not use after December 2005”. Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 21 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 2 2 2 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 2 2 3 2 Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 22 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. 2 Standard OP7 OP8 Regulation 15(1) 12(1) 13(4) Requirement The manager must ensure that a residents risk assessments are updated as their needs change. Residents with prevalent risk to falls must be discussed with the GP and a referral to a falls clinic considered. Records must be maintained. Staff must ensure that all creams and ointments are dated on the day that they are opened. In preparation for the mealtime staff must be aware of effective communication with residents and how this is hindered by a loud radio, appropriate actions must be taken to positively promote good communication with residents at all times. Timescale for action 28/08/06 28/08/06 3 4 OP9 OP14 13(2) 12(1) 18(1)(a) 30/06/06 30/06/06 5 OP19 13(4)(a,c) 6 OP22 23(2)(n) This requirement is carried forward from 12/11/05. The manager must ensure that 31/07/06 an audit is carried out of residents bedrooms to identify where there are broken radiator covers and wardrobe wall fixings. The manager must ensure that 30/09/06 the programme to provide DS0000004535.V290215.R01.S.doc Version 5.1 Page 23 Brookvale Care Home 7. OP24 8. OP27 9. OP27 10. OP29 11. OP33 12. OP35 13 14 OP36 OP38 15. OP38 appropriate signage for people with a dementia is progressed. 16(2)(c) Residents bedrooms must contain the furnishings as stated in the standard, and where it is not possible due to the size of the accommodation, this must be noted in the residents file. 18(1)(a) The manager must ensure that there are always sufficient staff on duty to meet the needs of the residents. The person in charge on a shift should be supernumerary and should not be included as part of the floor staff. 18(1)(a) The manger must ensure that all agency staff employed are familiar with where to source the information needed in order to provide the appropriate care to residents. Sch 2 The manager must ensure that all staff files contain a current photograph of the member of staff and that any gaps in the application form and work history are explored at interview. 24(1)(a,b) The manager must ensure that a formal Quality Assurance programme is implemented in the home. 17(2) The manager must ensure that Sch 4 the residents’ personal allowance (9)(a) expenditure records are regularly audited to ensure that receipts are present and balances are correct. 18(2) All staff must have regular documented supervision, at least 6 times per year. 23(4) The manager must ensure that, in line with the fire officers advice, the linen room doors are kept locked shut when not in use. 13(4)(c) Evidence must be provided that PAT testing has been carried out. DS0000004535.V290215.R01.S.doc 30/09/06 30/07/06 30/06/06 30/06/06 30/09/06 30/06/06 30/09/06 31/05/06 31/05/06 Page 24 Brookvale Care Home Version 5.1 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 OP19 Good Practice Recommendations It is recommended that the internal and external areas of the home be appropriately signposted, decorated and developed to aid guide and positively stimulate residents who have a dementia. It is recommended that the home’s management team consider the decommissioning of the rooms that fall below 9 square meters. Not completed and is carried forward. It is recommended that the home has a protocol drawn up addressing individual PRN medication needs for two of the residents. 2. OP23 3. OP9 Brookvale Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Care Home DS0000004535.V290215.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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