Inspection on 08/06/06 for Brookvale House

This inspection was carried out on 8th June 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 but made no statutory requirements on the home.

Other inspections for this house

Brookvale House 28/08/07

Brookvale House 02/02/06

Brookvale House 20/01/05

Brookvale House 03/09/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Brookvale House 4 Brookvale Road Portswood Southampton Hampshire SO17 1QL Lead Inspector Neil Kingman Unannounced Inspection 8 June 2006 10:25 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 House DS0000011775.V288863.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookvale House Address 4 Brookvale Road Portswood Southampton Hampshire SO17 1QL 023 8032 2541 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 Homes Limited Mrs H Ward Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (31), Old age, not falling within any other category (31), Physical disability over 65 years of age (8) Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons in MD and PD categories not to be admitted under 55 years of age Not more than 8 residents to be accommodated in PD(E) categories Date of last inspection 2 February 2006 Brief Description of the Service: Brookvale House is a home providing care and accommodation for up to 31 older people with age related mental health problems and illness associated with dementia. It is one of a number of homes in the Brookvale Homes Ltd group. Accommodation is arranged over two floors with a passenger lift affording access to rooms on the first floor. Most rooms are for single occupancy and several have en suite facilities. Staffing is provided 24 hours a day, including the provision of two waking night staff. The home is situated in a residential area of Southampton, close to the shops and local amenities of Portswood. There is an enclosed garden and patio area to the rear with seating for residents’ use. There is an off-road car park to the front, from which there is ramped access into the home via the front door. A number of entertainments and activities are provided on a frequent basis from both outside sources and in-house activities provided by the staff team. Weekly fees range from £328 to £420. The manager states that a copy of the home’s service users’ guide is provided to all prospective residents, or their representatives where applicable. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Brookvale House and brings together accumulated evidence of activity in the home since the last key inspection on 2 February 2006. Part of the process has been to consult with people who use the service, including telephone discussions with a community mental health nurse, and three relatives of residents who regularly visit the home. There were ten responses to the care home’s survey received from residents in the home, some with the help of a relative who represents them. Included in the inspection was an unannounced site visit to the home by an inspector on 8 June 2006. During the visit the inspector spoke with the manager and her assistant, staff on duty, several residents and a further two relatives who were visiting the home at the time. The inspector toured the building with the manager and looked at a selection of records. The responses from the consultations were very positive. What the service does well: Brookvale House provides a spacious and comfortable environment for the people who live there. A comment from a resident was, “staff are always pleasant and ready to listen to residents”. At the site visit the inspector noted how calm and relaxed the atmosphere was. This was considered significant in an environment with mostly mentally frail residents. Staff were observed to treat residents with sensitivity, good humour and patience. The home offers several comfortable communal areas with space for relaxing, activities and smaller areas for quiet conversation. Rooms are clean, comfortable and well personalised. The home meets residents’ healthcare needs and ensures that healthcare professionals are consulted and involved where appropriate. Families are kept informed with important information about their relative. The service can be summed up with a quote from one resident who said, “I think the home is well run, pleasant, and staff are pleasant and helpful. Food is excellent and well presented”. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 6 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. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that the care needs of the people who live at Brookvale House will be met by undertaking a proper assessment prior to them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: The last assessment of this standard identified a need for the registered person to ensure that newly admitted residents fall within the home’s registration categories. At this site visit the inspector looked at how the home managed the admission of the newest resident, who moved into the home in April 2006. Records showed, and the manager confirmed, that she undertook a full preadmission assessment of the individual’s needs at the hospital. A copy of the assessment was available in the resident’s care plan and showed that the resident was in category and that the process fully met the standard. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 9 The inspector spoke with a member of this resident’s family who was party to the assessment process and was satisfied with it. Pre-admission assessments carried out by the manager for two other residents were noted with their personal plans. Residents at Brookvale House are long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of care planning with an individual plan for each resident. They provide a good demonstration that residents’ health and social care needs are identified and met and include risk assessments and monthly reviews. The home promotes and maintains residents’ healthcare and ensures that access to healthcare services is available at all times. Medication is securely held and appropriate records maintained. The home ensures that staff respect residents’ privacy and dignity at all times, especially with regard to the arrangements for health and personal care. EVIDENCE: The principal of case tracking was used in a sample of three care plans. The intention was to look at the outcomes for residents in general by assessing all areas of care for those sampled. The sample included the newest admission to Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 11 the home, a resident with mobility difficulties and one with dementia. The inspector spoke with all three residents and with members of their families. Each resident has an individual personal care plan. Those seen contained an assessment of need together with a plan for daily living. General risk assessments and separate manual handling assessments were in place. Additionally, there was an assessment of the risk of each resident accessing the rear garden via the patio doors. Each had a record of significant events, a daily record and evidence of monthly reviews. Staff spoken with said that communication about residents’ needs was good, with regular shift handovers, staff meetings and supervision. The relatives of two residents sampled said that while they were not especially aware of the resident’s care plan they understood that care records were kept. The other relative was fully aware of her mother’s personal plan and in fact had a copy of it. They all felt the home kept them updated with information about the respective residents. The manager said that there was no incidence of pressure sores as staff practiced good continence and pressure area management. Staff spoken with were very clear about their role in preventing pressure sores. The manager described the good relationship the home has with healthcare professionals, and records evidenced the regular contact with GPs, optician, dentist, community mental health nurse etc. The inspector saw evidence of good recording of information following one such visit. The inspector spoke with a community mental health nurse who regularly visited the home. She confirmed that staff generally had a clear understanding of the needs of her clients, whose care was regularly reviewed. Medication is dispensed by means of a ‘Nomad’ system by staff who have completed accredited medication training. At the time of the site visit medication for residents was securely held, and records relating to the safekeeping and administration of medicines were found to be in order. During the course of the site visit the manager and staff showed an understanding of the importance of treating residents with dignity and respect. Relatives spoken with and residents who could give an opinion were full of praise for the staff and their approach to care. During the tour of the building the manager knocked before entering rooms and staff addressed residents by their preferred name. The manager said this was especially important for some residents who liked an unusual term of address. The home provides a portable phone and one in the hall for residents’ use, while some have their own installation in their room. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 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 and 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines in the home are flexible and informal. Activities are offered to suit the needs of the residents. Friends and family are made to feel welcome and can visit at any time. Residents unable to manage financial affairs are supported by their families. The promotion of choice extends to all aspects of daily living including personalisation of rooms, and meals. The nutritional needs of residents are satisfied with a varied and balanced diet of good quality food. EVIDENCE: In the responses to the care homes surveys returned from residents/representatives as part of the inspection process there were mixed messages about the activities on offer at the home, varying from them being always, to sometimes arranged. One commented that they were very interesting and informative, making it a very happy hour. One relative spoken with observed that there was not much variety in the activities offered but also Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 13 felt that the resident she represented was not a particularly social person so might not be that interested. In discussions the manager and her assistant highlighted such activities as arts and crafts, reminiscence, bingo, board games and visiting outside entertainers. They referred to a calendar of future events, which included trips out to places of interest for those who wished to take part. Church services are regularly held in the home and one resident attends the local church each Sunday. During the site visit most residents who were able to express an opinion showed an interest in the organised activities. After lunch one of the staff took some of the residents for a bingo session. From their reaction it was clear they enjoyed the experience. The inspector observed that some residents enjoyed the company of others in the communal areas while others preferred to keep their own company in the privacy of their rooms. At the last inspection a good practice recommendation was made to consider the specific needs of people with dementia by introducing strategically placed signs to help with their cognition. The inspector noted that toilets and bathrooms were signed and residents had their names on their room doors. While this would not guarantee to compensate for the disability of dementia the manager and her assistant made the point that each resident’s needs were individually assessed and picture symbols would be utilised if it would help individual residents. Visiting arrangements can be found in the service users’ guide and displayed in the hall. Visitors are welcome at any time but are requested to avoid mealtimes where possible. Residents can receive visitors in their own rooms or any of the communal areas. In addition to the main lounges there are two other areas in the home, which offer quietness and some privacy if required. Residents spoken with felt they had some choice regarding routines in the home, especially times of rising, going to bed and what they did during the day. When asked about bathing they said they could take a bath by just asking the staff but were happy to fit in with the regular bathing routine. During the tour of the building the inspector noted varying amounts of personalisation to rooms, which reflected their needs and preferences. Residents unanimously approved of the food provided by the home and the relatives spoken with confirmed this. One resident described the food as, “excellent and well presented”. The inspector spoke at length with the home’s cook, who has worked at Brookvale House for many years. She said that she knew well the preferences of the residents and concentrated on traditional wholesome meals, as this was what they generally liked. The inspector noted that drinks and biscuits were offered to residents through the day between meals. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 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 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints are treated seriously and given an appropriate response. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. Procedures for responding to suspicion or evidence of abuse are robust. EVIDENCE: The home has a policy and procedure for dealing with complaints. The inspector looked at the complaints register and noted the last complaint from a resident was recorded in May 2006 and described the type of complaint and what was done about it. Residents spoken with had no complaints about the service. While they did not fully understand the official details of the procedure they felt they could approach the manager, or even the staff if they had any concerns. Two visiting relatives spoken with had knowledge of the complaints process and felt able to approach the manager with any concerns. In May this year the family of an ex-resident made a complaint, consisting of five elements, which criticised the home’s approach to the care of confused residents, the way that laundry was handled, the manager’s attitude and some specific behaviour on her part. This complaint was referred to the proprietors for investigation. A written response was received at the Commission detailing the approach to the investigation, the findings, and recommendations made. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 15 The investigation concluded that no elements to the complaint were substantiated. However, some recommendations were made to improve the home’s approach to quality assurance. These are described in more detail later in the report. The home has an adult protection policy and procedure, and staff training covers abuse. Staff spoken with were very clear about how to recognise abuse, what to do, and the importance of reporting issues of concern without delay. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Brookvale House provides a warm, welcoming, clean and comfortable environment for residents to live in. However, an issue involving the bath hoist in a first floor bathroom needs to be resolved. On the day of the site visit the home was clean, hygienic and there were no unpleasant odours. EVIDENCE: Brookvale House has been a residential care home for older people for many years and while not purpose built has been converted and extended over the years to be suitable for its stated purpose of providing a safe, manageable and comfortable environment for the people who live there. A passenger lift affords access to rooms on the first floor. All areas of the building are accessible to residents including the garden, which can also be reached via patio doors. Due to a small lip at floor level that could present a risk of tripping, residents likely to use the doors are individually risk assessed. The Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 17 rear garden is well kept and has seating for residents’ use during the summer months. The home is generally comfortable, well furnished and decorated. The home has undergone some development to convert a conservatory into a solid structured dining room. The manager confirmed that plans are in place to upgrade the kitchen, laundry, office and a bathroom, and also to create some additional rooms. Work is expected to commence in July this year. At the last inspection a requirement was made for the home to address the problem of the enamel coating on one of the baths. Due to the bath hoist not being raised sufficiently in use some enamel on the top edge of the bath had worn away, leaving the metal exposed. It was clear that an attempt had been made to coat the exposed metal with a proprietary enamel paint. However, this had limited success since the underlying cause of the problem is the hoist. The inspector noted the underside of the hoist was suffering signs of wear and tear, with the plastic coating peeling off the frame. In discussions with the manager she recognised the potential risk of cross infection and agreed to resolve this problem once and for all. The bathroom itself was of a warm and comfortable temperature. Residents and relatives said they were generally satisfied with the environment, although the community mental health nurse observed that urine smells were sometimes present at her visits. The manager said they had experienced a particular problem with behavioural incontinence in the past but this had been resolved. Eight out of ten of the care home surveys returned indicated the home was always fresh and clean. The inspector toured all areas of the building during the site visit and noted them to be clean, hygienic and free from unpleasant odours. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and mix of skills are adequate to meet residents’ needs. To ensure residents are in safe hands arrangements are made for staff to undertake NVQ training. However, at the time of the inspection the home fell short of the minimum standard of 50 qualified at NVQ level 2 or above. The home operates a robust recruitment procedure. Staff turnover is low and no new staff have been recruited since this standard was last assessed. The staff training and development programme ensures the residents’ needs are met in line with the aims of the home. EVIDENCE: The home employs fourteen care staff and on the day of the site visit there were twenty-eight residents in the home. Staff rotas showed, and the manager confirmed, that a minimum of three care staff and the assistant manager are deployed each day between 08:00 and 20:00. The manager works in a supernumerary capacity. Additional domestic, catering, laundry and maintenance staff are employed. Overnight there are two wakeful care staff on duty. These staffing levels are considered adequate for the current needs and numbers of residents in the home. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 19 During the site visit the inspector noted a calm and relaxed atmosphere, with staff performing their duties in an unhurried way. All staff, visiting relatives and the community mental health nurse spoken with felt there were always sufficient numbers of staff on duty. Seven out of ten responses to the care home’s survey from residents/representatives indicated there are always staff available when needed. The other three indicated usually. Currently 43 of care staff have achieved the NVQ at level 2 or above. One carer has almost completed the training and others are enrolled on the training programme commencing in September. This should ensure the home achieves the ratio of 50 NVQ trained staff. As regards recruitment procedures no new care staff have been recruited to the home since this standard was last assessed. At the last inspection shortfalls were identified in some documentation. At this inspection the manager was very clear that no member of staff would be recruited without first going through a robust recruiting procedure, which includes security and reference checks. Staff are scheduled to attend all statutory training, which includes health and safety, first aid, food hygiene, manual handling and adult protection. The inspector noted a training plan, which evidenced achievements and identified training needs, and a sample of qualification certificates in staff files. In discussions with visiting relatives there were no concerns raised about the performance of staff, indeed the community mental health nurse confirmed that staff underwent ongoing training in dementia awareness. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has the experience together with the relevant management qualification to run the home and meet its stated purpose, aims and objectives. She is currently enrolled on a training programme to achieve the NVQ at level 4 in care. The home has developed effective quality assurance systems for measuring its performance based on seeking the views of residents, representatives and stakeholders. The home provides a facility to safeguard residents’ monies or valuables on request. Involvement in residents’ finances is limited to assisting three with their weekly allowances. Currently the arrangements do not provide for a signature to evidence their receipt of the amounts. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 21 While policies, procedures and staff training ensure so far as is reasonably practicable the health, safety and welfare of residents and staff an electrical inspection is required to be carried out by a NICEIC qualified contractor. The home is required to review its procedures for reporting incidents/accidents to the Commission. EVIDENCE: The registered manager Mrs Ward has managed the home successfully for the past eight years. She has achieved the Registered Managers Award and has enrolled on the training programme to achieve the NVQ at level 4 in care, at which point this standard will be fully met. At the last inspection the manager was advised to consider how views of the residents are obtained. It basically identified shortfalls in the home’s quality assurance procedures. The inspector was shown a new quality assurance procedure, developed by the proprietors from recommendations made following the complaint investigation referred to earlier in the report. The new procedure, which has already been implemented, comprises a questionnaire for residents/representatives, and questionnaires for stakeholders, including chiropodist, hairdresser and a range of healthcare professionals. The manager showed the inspector a number of completed questionnaires and confirmed that surveys would be carried out at intervals from now on. The home generally has no involvement with residents’ financial affairs other than to provide a facility for safekeeping money or valuables on request. However, the manager described an arrangement whereby a small number of allowances are collected and given to residents. It is recommended that these residents should sign as having received the amounts. The manager confirmed that they have the cognitive ability to do so. All care staff undertake statutory training, which includes health and safety, food hygiene, first aid and manual handling. The home’s pre-inspection information signed by the manager confirmed that policies and procedures were in place to ensure safe working practices in the home. It indicated that since the last inspection there had been three admissions to Accident and Emergency. Only one if these incidents had been reported to the Commission as required by regulation. In discussions with the manager it was agreed that the home will notify the Commission of all accidents involving residents, where staff are sufficiently concerned about their wellbeing as to seek medical advice. In addition to accident records the inspector looked at fire logs, public liability insurance and the gas heating system certificate, all of which were in good Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 22 order. An electrical inspection is required to be carried out by a NICEIC qualified contractor (the last electrical certificate expired in February 2006). Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 2 Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 23 Requirement To resolve the issue of the bath hoist in the first floor bathroom, so as to: • Prevent the risk of cross infection where the plastic coating has peeled off the seat frame. • Prevent the seat frame from rubbing the enamel off the lip of the bath and exposing the metal (requirement outstanding from last inspection). To report to the Commission all accidents involving residents, where staff are sufficiently concerned about their wellbeing as to seek medical advice. To make arrangements for an electrical inspection by an NICEIC qualified electrician Timescale for action 31/07/06 2 OP38 37 30/06/06 3 OP38 23 31/07/06 Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 25 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 OP35 Good Practice Recommendations The residents who have allowances collected for them to sign as having received the amounts. Brookvale House DS0000011775.V288863.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 House DS0000011775.V288863.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!