Inspection on 20/09/05 for Brookvale Lawn

This inspection was carried out on 20th September 2005.

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

Other inspections for this house

Brookvale Lawn 07/03/07

Brookvale Lawn 13/03/06

Brookvale Lawn 14/02/05

Brookvale Lawn 25/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Brookvale Lawn 15 Lawn Road Portswood Southampton Hampshire SO17 2EX Lead Inspector Christine Hemmens Unannounced Inspection 20th September 2005 10:00 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 Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brookvale Lawn Address 15 Lawn Road Portswood Southampton Hampshire SO17 2EX 023 8057 7786 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 E Raison Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2005 Brief Description of the Service: Brookvale lawn is one of a number of residential services owned by the same proprietor. Brookvale Lawn predominately provides service for older persons who have some degree of age related frailty. The home is a modern purpose built residential service situated in a residential area of Southampton, close to the local amenities of Portswood and a short ride away from Southampton City Centre. The home is staffed twenty-four hours a day by care staff and in addition the home is supported by a separate team of domestic and catering staff. The accommodation is organised over three floors, which are all accessible, by a regularly serviced passenger lift. All bedrooms are designed to accommodate single occupancy, however an extra room is provided for couples or residents wishing to share. The home has a communal lounge and dining room and each level has a good size lounge and in addition the home has a chapel and hairdressing facilities. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first announced visit to the home to be undertaken this year. The inspector was assisted with the inspection by the registered manager Mrs Raison and her deputy manager. Both managers were very supportive. The inspector met with a small number of residents, speaking at length with one resident who had lived in the home for approximately three years and could provide the inspector with a clear overview of their thoughts and feeling of the service provided. The inspector met with a small number of relatives and a visiting Community Psychiatric Nurse who spoke highly of the service. In addition the inspector met with a member of staff who discussed briefly her roles and responsibilities within the home. At the time of the visit the home appeared relaxed and residents were engaging in activities of their choice. What the service does well: Brookvale Lawn does well to provide a good standard of care and support to the residents and their relatives. Residents are fully assessed before moving in to ensure the home can meet their needs adequately and the home is well supported by health care professional such as GP’s and district nurses. A community psychiatric nurse informed the inspector that Brookvale Lawn is a very nice home and he had no concerns regarding the level of care provided to the residents, “they don’t hesitate to call me if they need help or advice”. The home ensures that staff are made aware of the needs of the residents and encourage the residents to take part in the review and evaluation of their care. The residents were very complimentary of their care and one resident stated, “They can’t do enough for you, they are always very nice and always give you a smile”. The home supports the residents to spend their days as they wish and respects this. One resident said “they never pressurise you to do what you don’t want to do and you can spend your day as you wish”. The resident also went onto say that the staff are very respectful. The home prides itself in providing a very high standard of accommodation and facilities for the residents with activities that stimulate and occupy them. The residents with whom the inspector spoke with said they were very happy with their room, the activity and the food was very good. The home is very welcoming and visitors to the home said they were always made to feel welcome, are always offered a drink and a biscuit and were kept informed of their relative’s wellbeing. One relative said “ the staff are very kind and the manager is very approachable, I have no worries about asking her for anything”. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 5 The home ensures it can appropriately support and meet the needs of prospective resident by undertaking a thorough assessment and offering a trial placement. EVIDENCE: The inspector viewed the personal file of a resident who had recently moved into the home and established that the home undertakes a thorough assessment to ensure it can meet the residents needs. The manager and deputy manager informed the inspector that they try to undertake joint visits, however they will always assess a resident before confirming if they can meet their needs and before resident move in. The manager spoke of the difficulty of sometimes obtaining information, especially when visiting hospital wards as very often the nursing staff are too busy to stop to provide the information they need. However information is obtained from relatives and other professionals such as community psychiatric nurses (CPN) and GP when required. Further discussion took place in considering the advantages of obtaining historical information on the residents to form part of the assessment process Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 9 and form a pen picture of the resident. This was recommended following the previous visit to the home, the managers are requested to consider the recommendation and benefits to both the carer and residents in obtaining this information. The home offers a four-week trial period to continue the assessment process and establish if the resident is settled and happy to remain in the home and if the home can fully meet their needs. The manager stated there is some flexibility on the timescale of four weeks if the home and the resident feel its necessary. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 The home works well to meet and respect the residents’ health and welfare needs through the care planning process and links with health care professionals. However further work is required to ensure all staff are aware of when to administer as required medications” (PRN) EVIDENCE: The inspector viewed three residents’ personal plans that provide personal information on the residents NOK, GP and Social Worker etc… In addition to personal contact and financial information held on the residents the home have in place for each resident care plans that have been developed from the assessment documentation. These describe the needs of the residents in terms of support with personal care and their health and welfare needs. The inspector advises the manager to develop the plans further to detail how the care must be carried out. Discussion took place on the benefits to the residents by developing the plans in this way and so providing a consistency of care. An example of toileting was provided. There is evidence of care plans Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 11 being regularly reviewed by the senior carers and where possible the resident and a daily record of the residents wellbeing. The home undertakes risk assessments on residents where there is an area of concern to their health and welfare. The risk assessments identify the risk and how it can be minimised an example of the home attempting to safeguard a resident from the leaving the home by leaving a message on the door. The resident frequently leaves the building, this demonstrates the home has considered the risk to the residents and has put in place measures to minimise the risk of the resident leaving the building unescorted. The managers informed the inspector that they continuously review and assess risks and the needs of the residents and will support them accordingly, an example of supporting a resident to move downstairs was provided in order that closer observation by staff could be carried out. Residents who are at risk of falling and whose needs change through ill health or deteriorating frailty are assessed by the district nurse and the physiotherapist if required and a decision is then made if the home can continue to support the resident. The home is fully supported by health care professionals, on the day of the visit a GP visited and the inspector spoke at length with a visiting community psychiatric nurse (CPN) who spoke admiringly of the staff and professional approach adopted by the home and its staff to meet the mental health needs of the residents. The CPN stated this was one of the nicer homes he visited in the area who were always welcoming, called when they need assistance and put the needs of the residents’ first. The home supports the residents to administer their medication by staff who have undertaken a comprehensive accredited safe administration course. Residents who can administer their own medication are risked assessed. The inspector observed a member of staff administering the medication, the medication was administered to the residents in a dignified and respectful manner, however the member of staff must not dispense the medication into her hand. This was discussed with the member of staff and the managers who stated they would ensure that this did not happen again as this is not usual procedure. The inspector agreed not to make a requirement on this occasion but will review the procedures during the next visit to the home. The managers must ensure staff responsible for administering “as required” medications (PRN) are fully aware of when the resident requires it, especially if the resident is unable to verbalise their discomfort or how they are feeling, therefore the manager must ensure all residents on PRN medications have care plans in place to support their administration. The managers may also wish to consider placing photographs of the residents on the medication recording sheets to assist with the identity of those residents who may have difficulty stating their name. The inspector spoke at length with a resident who was able to provide evidence that the staff respect and support them with dignity and respect. The resident informed the inspector that nothing is too much trouble for the staff and the manager, “they go out of their way to make you feel comfortable and make sure you have what you need”. “They do not pressurise you to do things you Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 12 don’t want to do and you can spend your day as you wish”. The resident stated staff always knock on the bedroom door before entering, ask if you are okay and if you need anything. “When they support me with my personal hygiene this is always done in a respectful manner and I am encouraged to do as much for myself as I can”. The inspector observed staff adopting a respectful approach when conversing and assisting the residents. These approaches demonstrate that the home values and respects the health and welfare needs of the residents. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 13 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 The home considers the individual lifestyles of the residents and supports residents to maintain links with family and friends. EVIDENCE: The inspector spoke with a small number of residents and relatives and observed a number of activities that evidenced that the home considers the individual lifestyles, likes, dislikes and cultural beliefs of the residents. On the day of the visit the home a group of residents were involved in gentle armchair exercises to relaxing classical music. The residents appeared to enjoy this and later some informed the inspector they found the exercises helpful in keeping them mobile. In addition to armchair exercises the same outside entertainer visit the home weekly to undertake a reminiscence therapy and quiz session. The manager stated that the residents appear to enjoy these sessions. Regular religious services are held within the home in homes chapel. The manager stated that religious services are generally well attended. The home has a library and quiet area. Library books are in large print and talking books have been purchased for the visually impaired. One resident informed the inspector that they can join in activities if they wish, however this is not forced on people if they do not want to attend. Residents can receive papers and magazines if they wish and the majority of the residents have televisions in their own rooms. The manager informed the Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 14 inspector that they organise days out or a trip to the local pub if residents wish to go. The inspector observed staff regularly engaging in discussion and friendly banter with the residents. Through the course of the day the inspector observed visitors coming and going to visit their friends and family. The inspector spent some talking to relatives who were very complimentary of the home and staff and stated that the home had been recommended by a local hospital as being one of the best homes in the area. The visitors stated they were always made to feel welcome and kept informed of their relatives’ wellbeing. The inspector observed the visitors being offered tea and biscuits and cheeky friendly banter taking place between the relatives and staff. They stated they could meet with their relative where and when they liked and either went to the resident’s bedroom or used one of quiet areas in the home. The inspector did not fully assess mealtimes and if residents individual dietary requirements were being met, however the inspector did observe residents receiving a well-balanced hot meal at lunchtime of home made chicken pie and vegetables and some residents’ receiving support where required. The dining room is tastefully decorated and dining room tables are dressed with tablecloths, napkins and condiments. One resident informed the inspector that the meals were very nice and plenty of drinks and snacks are provided throughout the day. Another resident informed the inspector that the staff make sure she drinks plenty and provide her with a particular drink to guard against infections that she is prone. The resident saw this as very caring and considerate. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 15 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): The home provides an environment where residents, relatives and visitors feel confident that their complaints and concerns are listened to and acted upon. The home as far as feasibly possible protects residents from risk of potential abuse. EVIDENCE: Standard 16 and 118 were not fully assessed on this occasion, however the inspector spoke with some visiting relatives who stated they had no complaints and if they did, they felt assured that the manager would deal with their concerns in the appropriate way. The visiting CPN also stated that he had never had any cause for concern for the way the home supported the residents with their health and welfare needs. There was evidence of a complaints procedure displayed in the entrance hall of the home and the manager stated they had not received any complaints in the home recently. The residents with whom the inspector spoke with stated they didn’t have any complaints and felt the home and the staff were very nice. “Nothings to much trouble and they will always listen and try and sort things out for you if you have a problem”. The manager and some staff with whom the inspector spoke with stated that they had received training in protecting vulnerable adults and were aware of the policy and procedures to following in the event of witnessing or suspecting an incident of abuse. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 21 The home provides a homely, friendly and clean environment for the residents to live in. However the manager must ensure all areas home and equipment used by residents is safe. EVIDENCE: The home is large and accommodated over three floors, the ground floor provides communal facilities, which is spacious, bright, airy and tastefully decorated. On each floor the home has its own lounge which again has been tastefully decorated and furnished with high quality furnishings, these rooms provide a pleasant view of the local community and the river Itchen. In addition the home has a chapel, hairdressing facility and library. Each floor has ample toileting and bathing facilities that are kept to a high standard of cleanliness. However the inspector observed in one bathroom a cracked bath, which was sharp to touch. The manager was informed that the panel needed to be made safe without delay and then repaired or removed. The manager got onto dealing with the broken bath panel straight away and Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 17 later confirmed that the bath panel would be replaced as soon as possible. This will be reviewed at the next visit to the home. The manager is advised to undertake regular maintence checks of the home and report defects that could potentially cause harm to residents. The inspector viewed a number of the residents’ bedrooms and found these to be personalised reflecting the residents history and personality. Again the bedrooms are very nicely decorated and furnished with very good quality furnishings. The inspector met with a resident in her own room who stated she had the luxury of a separate bedroom and lounge. The lounge being comfortably furnished with the residents’ own furniture. All bedrooms are fitted with en suite toilet and hand washbasin facilities. The resident confirmed that the staff assist her to keep her rooms clean and tidy and regularly change the bed linen. The home has a shaft lift to all floors that is large enough to accommodate resident in wheelchairs comfortably. A number of residents require assistance to mobilise and some resident use wheelchairs to get about. Discussion took place on residents living on the first and second floor who need wheelchairs to get about. The manager confirmed that the residents has been offered downstairs accommodation but did not wish to move. The residents have been risked assessed in the event of a fire breaking out in the home and a clear procedure in place for safeguarding and protecting the residents until help arrives. However the manager may wish to consider exploring the market for especially adapted stair chairs in order that in the event of a fire the resident can be moved safely to another level if required. The garden was not viewed on this occasion, however a small patio area with a variety of planted tubs to the front of the home offers a pleasant area to sit in the summer and watch people coming and going. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 and 28 The home attempts to staff the home in such numbers to meet the needs of the current residents and protect residents by employing the appropriate checks, however further work is required to ensure the correct numbers of staff are employed and the manager makes herself clear on the current employment legislation. EVIDENCE: At the time of the visit the home was able to demonstrate that it employs enough staff to cover all areas of the home at all times of the day, with the support of agency staff. In addition to care staff the home employs domestic, laundry and kitchen staff. The inspector viewed a typical weeks rota and was informed by the managers that staff are deployed in such numbers as to cover and supervise the individual assessed needs of the residents. The managers’ informed the inspector that on a typical morning they would have three carers, one senior and the manager on duty, a carer on each floor and the senior floating to offer support. A similar rota is adopted for the afternoon and evening and there are two waking night staff. The manager advised that the home has a full time vacancy, and that they are hoping to cover the weekends with an additional twenty-four hours. Although the home demonstrates with the aid of agency that they can meet the needs of the residents a home of this size should be providing approximately 645.97 hours (this is a guide based on the Residential Forum). During the previous visit to home it was identified that the home was running at 514 hours support a loss of 139.97 hours, further vacancies have dropped the total number of staff hours employed by the home to 304 hours a week a Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 19 significant drop in the hours recommended by the Residential Forum. The manager is advised to reassess the dependency levels of the current residents and adjust the care staff hours appropriately to meet their needs. The manager is aware of her roles and responsibilities in ensuring staff are employed adopting and following the appropriate checks such as taking up references and applying for a criminal record bureau check (CRB), however there was some confusion on taking up an application to check staff against the POVA list (protection of vulnerable adult) and the employment of staff under supervision before a full CRB check has been completed, following a POVA First check. Although the manager had not started anyone in the home without the appropriate checks being undertaken the manager appeared unaware and confused with the new guidance in relation to CRB and POVA checks. Therefore the manager is advised to make herself aware of the current legislation. Staff records will be viewed as mandatory at each visit and the manager was made aware that the legislation around employing staff has been tightened and immediate action is considered where non-compliance with registration is apparent. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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 and 38 The home has a stable management team who are skilled and competent to undertake their roles and responsibilities satisfactory. The home as far as feasibly possible provides a safe environment for residents to live in, however the manager must ensure this is fully demonstrated through appropriate record keeping. EVIDENCE: The inspector established through the course of the inspection, through observation and discussion that the manager and deputy manager work well as a team, share responsibilities equally and have an open and inclusive approach to staff and residents. The manager stated “the door to the office is always open so I am aware of what’s going on and to allow both staff and residents and their visitors to come and speak to me when they want”. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 21 The manager is currently undertaking the Registered Managers Award (RMA) qualification and the deputy manager has completed her National Vocation Qualification (NVQ) at level three and hopes to go onto to do level four. Both managers stated they keep themselves up to speed with mandatory training and training relevant to the residents needs. However the manager must ensure she keeps herself aware of current legislation in respect of the National Minimum Standards and Care Homes regulations. I.e. Recruitment of staff. The manager as far as feasibly possible maintains a safe environment for the residents to live. The home is very clean and tidy and other than a broken bath panel areas of the home viewed by the inspector appeared safe. Harmful substances (COSSH) are kept safe and the home can evidence that the it has had all the appropriate checks undertaken on its appliances such as the gas boiler, electrical and servicing of the lift shaft and bath hoists. The home has a very good fire risk assessment and risk assessments are in place for those residents who use wheelchairs and have bedrooms on the first floor. The managers keep a record of fire training and this indicated that staff regularly receive fire training, however the manager must ensure a record is kept to evidence that fire systems such as emergency lighting and fire alarms are regularly checked. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 22 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 3 X 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 2 X X X X X STAFFING Standard No Score 27 2 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 2 Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA7, YA10 Regulation 12(1)(2) Requirement The registered manager is required to ensure care plans state “How” the individual care of the resident is to be carried out. I.e. toileting. The registered manager must ensure the residents receiving “As required medications” have care plans in place detailing when the medication should be given. The registered manager must ensure regular checks are undertaken on all fire safety appliances such as fire alarms, emergency lighting and extinguisher and an up to date record is kept. The registered manager must ensure she makes herself aware of the current legislation in respect of recruitment of staff. DS0000011776.V251802.R01.S.doc Timescale for action 30/11/05 2 YA9 13(4) 30/11/05 3 YA38 23 30/10/05 4 YA29 and YA31 10(3) 30/10/05 Brookvale Lawn Version 5.0 Page 24 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 YA3 Good Practice Recommendations The registered manager is advised to include in each residents assessment process pen picture/historical information especially where there is memory loss. This recommendation has been repeated. 2 YA9 The registered manager is advised to place a photograph of the residents on to the medication administrationrecording sheet (MAR) to provide clearer identification for those residents who may have difficulty stating who they are. Brookvale Lawn DS0000011776.V251802.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lawn DS0000011776.V251802.R01.S.doc Version 5.0 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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