Inspection on 18/10/06 for Brookview Nursing Home

This inspection was carried out on 18th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Brookview Nursing Home 26/09/07

Brookview Nursing Home 06/02/07

Brookview Nursing Home 26/04/06

Brookview Nursing Home 23/01/06

Brookview Nursing Home 05/09/05

Brookview Nursing Home 02/03/05

Brookview Nursing Home 20/10/04

Brookview Nursing Home 29/03/04

Brookview Nursing Home 07/10/03

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

CARE HOMES FOR OLDER PEOPLE Brookview Nursing Home Holmley Lane Dronfield Derbyshire S18 6HQ Lead Inspector Sue Richards Key Unannounced Inspection 18th October 2006 09:30 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 Brookview Nursing Home DS0000002046.V316432.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. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookview Nursing Home Address Holmley Lane Dronfield Derbyshire S18 6HQ 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) 01246 414618 01246 414657 Brookview Nursing Home Ltd Mrs Diane Martin Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2006 Brief Description of the Service: Brook view Care Home provides nursing and personal care for older persons, with the number of service users to be accommodated in accordance with the stated conditions of the homes registration. The registered provider took over ownership of the home on 17 March 2003 and has invested considerably in the substantial redevelopment and upgrading of the home and its facilities. There are 54 single bedrooms, 44 of which have en suites. There are three double bedrooms, one having and en suite facility. There is a choice of communal bathing, shower and toilet facilities suitably located. There two separate lounge areas and one combined lounge/dining room. Suitable equipment is provided to assist service users who may have physical disabilities, including an emergency call system located in all areas which service users access and a shaft lift giving access to all levels of service users areas. Level and ramped access is provided to garden areas, with seating provided. Visiting to the home is open and service users are provided with care and support from a team of nursing, care and hotel services staff, led by the registered manager who has external management support. Fees charged per week are in accordance with agreed terms and conditions between the home and individual resident. They detail local authority purchasing contracts where individuals are funded via these or where privately funded they are in accordance with a written contract agreed between the home and individual resident. Fees charge are as follows:Residential clients (personal care only) - As at 26.04.06 fees range from £289.70 to £369.70 per week. Fees are banded and determined in accordance with individuals assessed needs/levels of care and individual accommodation. Nursing residents per week - As at 26.04.06 fees range from £409.40 to £509.40. These fees are current as at the time of the inspection. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of the inspection there were 51 service users accommodated, including 21 receiving nursing care. The key national minimum standards for older persons were inspected as detailed in its document by the Department of Health. Case tracking was undertaken as part of the methodology. This involved the selection of four service users whose care and service provision was examined more closely in respect of those national minimum standards, including discussions with them and their representatives, staff providing their care and examination of their care and related records. This report is based on information held about the service by the Commission, including its service history, together with information provided by the home by way of a preinspection questionnaire and a site visit to the home. What the service does well: What has improved since the last inspection? There is an effective approach to the assessment of service users admitted to the home, including the accurate recording of their individual needs and their care plans provide better details in respect of their social and emotional care needs. Clinical trigger tools are more effectively utilised and reviewed resulting in the main, in a more consistent approach to ensuring service users access treatment and advice from outside health care professionals, with records kept of these (excepting medicines risk management). The provision of leisure and recreational activities for service users has developed considerably. The provision of dedicated staff to cover the dining room at mealtimes provides improved assistance for residents there and the reviews of menu provision have resulted in increased variety and choice for service users to a standard, which they state is excellent. A staff training needs analysis has been undertaken, with many areas of staff training having being undertaken or planned. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brookview Nursing Home DS0000002046.V316432.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 Brookview Nursing Home DS0000002046.V316432.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Quality outcome in this area is adequate. This judgement has been made using evidence available, including a site visit to this service. There is an effective approach to the assessment of service users admitted to the home. However, the inconsistent arrangements in respect of staffing levels and staff deployment often impact on staffs’ ability to meet service users needs in a timely and consistent manner. EVIDENCE: Case tracking was undertaken in respect of four service users accommodated. This included discussions with them about their needs and how they were met, in accordance with individuals’ given capacities. Discussions were also held with relatives of individual service users and also with individual staff regarding residents’ needs and the arrangements for these to be met, including the arrangements for care delivery on a day-to-day basis. Feedback was positive in respect of staff skills and hard work, although significant concerns were Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 9 raised regarding insufficient staffing levels. (See also complaints and staffing sections of this report). Care delivery was operated by way of staff teams, one to each floor, which staff was allocated to on a daily basis. Staff felt that this needed further development to ensure improved allocation of responsibility and continuity of care by way of named nurse/key worker system, which was not in total operation. The recorded needs assessment information for each of the service users case tracked was examined. These were recorded in accordance with a recognised holistic model of assessment and were comprehensive and well documented. Individual’s individual routine and lifestyle preferences were also included in their care plans. Brookview Nursing Home DS0000002046.V316432.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health care needs were well generally well accounted for, although the deficits in practise regarding some aspects of medicines storage, administration/record keeping and risk management did not always best promote the safety of service users. Service users are treated with respect and their right to privacy are well promoted, although their dignity was not always effectively promoted. EVIDENCE: The written care plans of each service user case tracked were examined. These were formulated in accordance with their individual needs assessments within a framework of risk management, with the exception of one area of care planning for one service user concerned with their medicines. Otherwise, written care plans met with relevant clinical guidelines concerned with the care Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 11 of older persons and had recorded reviews. Evidence of the involvement of service users in the formulation of their written plans was not always recorded. One of the service users spoken with expressed some dissatisfaction about aspects of their care not being in accordance with their preferences giving specific examples and confirmed they had not seen their written care plans and was not involved in these. Health care needs and the arrangements for service users to access outside health care professionals for the purposes of routines and specialist healthcare screening were appropriately accounted for and records maintained in respect of these. The arrangements for the management and administration of medicines in the home, including that relating to self-administration policy were examined. Medicines are stored in suitable cabinets in a dedicated room, which is kept locked. The temperatures of this room was very hot on entry and despite the use of a fan, daily recorded room temperatures were in excess of 28 degrees centigrade, which is too warm for medicines storage. Discussions were held with staff regarding the management of potential implications and risks to one service user case tracked, evidenced by the information recorded on their medicines administration record (MAR) sheet. There was no recorded risk assessment/formal review or effective care plan protocol as agreed with that individual and the multidisciplinary team concerned with that individual’s care in respect of this. Written policy and procedural guidance was provided for staff in respect of the management and administration of medicines. This was largely satisfactory and in accordance with recognised national and professional guidance, although there was a lack of information in respect of assessment process for any persons who may wish to retain and administer their own medicines. In addition, gaps of recording were observed on some of those MAR sheets examined. Written feedback via resident surveys and also verbal feedback from residents and their representatives during the inspection indicated that staff treat residents with respect and strive to promote their dignity and privacy. However, all felt that varying staffing levels meant that staff often did not have sufficient time to ensure that individuals’ choices were met in respect of their preferred daily living routines and that individual’s dignity was not always effectively promoted. Concerns were also raised by some regarding the prescribed administration of medicines required to be taken at specified times relating to the intake of food, particularly at breakfast time. Brookview Nursing Home DS0000002046.V316432.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provision of leisure and recreational activities for service users is developing well. Support for them to maintain their contacts and relationships with families and friends, is excellent, as is the variety and quality of food provided. However, the inconsistent and often inadequate staffing arrangements significantly undermine service users rights to exercise their choice in these areas or to receive their meals at suitable intervals. EVIDENCE: At the previous inspection for this service in April 2006 it was identified that the organisation of activities and occupation for service users was minimal. Since the home have employed an activities co-ordinator who works in the home on a part time basis. Discussions were held with her about the organisation and arrangements in the home to enable service users to engage in social and recreational activities of their choice, which had developed Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 13 considerably since her appointment. Discussions were also held with service users and their representatives, together with staff, who all felt that there were significant improvements in this area. Records were also maintained regarding activities provision and individual service users social care needs and engagement in these. However, feedback obtained from service users indicated that improvement were still needed in terms providing additional assistance to enable more physically dependant service users the option of engaging in activities. Discussions and feedback obtained via complaints and concerns and service user comment cards also indicated that staffing levels often constrained some service users opportunities to exercise their choice in relation to leisure and social activities, food, meals and mealtimes and routines of daily living. There was no service users with diverse cultural or religious needs accommodated. Service users spoken with said they had opportunity to engage in religious activities in and outside the home. This was also observed during the inspection. All residents spoken with said they were able to have visitors at any time they chose and many received visitors during the inspection. The organisation of meals and mealtimes has continued to develop over the year with full menu reviews and the provision of waiting staff to ensure the efficient serving of meals. Feedback from service users and their representatives was that the standard of food provided was excellent, with good variety and choice provided by large pre-printed menus, which was displayed on each dining table and also circulated in consultation with them. Baskets of fresh fruit were provided, which residents said is available on a daily basis. The inspector observed the organisation and serving of breakfast, lunches and tea were observed over a two-day period. Concerns continue to be raised by service users and their relatives and also staff, with regard to the impact of insufficient and/or inconsistent staffing arrangements, which often result in service users not having their meals at appropriate times and which suit them. On the first day of the inspection this was not an issue with sufficient staffing arrangements provided. However, the Inspector returned on the second day and found insufficient staffing arrangements. A significant number of service users were still being assisted to get up at midday and some had not received breakfast. Discussions held with them and their representatives indicated that this was not in accordance with their choices or daily living preferences and that some had not had a snack meal since the evening before, which was well in excess of 15 hours duration. All spoken with said this was a frequent occurrence resulting a short time period for residents to receive their meals of the day. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 14 Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Service users and their relatives/representatives are not confident that their complaints will be listened to, taken seriously or acted upon EVIDENCE: Information provided by the home in the pre-inspection questionnaire completed by the manager and also the home’s complaints records details a total of nine complaints received between 01 January 2006 and 30 September 2006. Seven of these were made by named relatives of individual service users, with regard to their dissatisfaction with the standards of care and in some instances alleging a lack of care. Two of the seven complaints were referred and investigated via Derbyshire County Council’s safeguarding adults procedures. All have been either partially or substantially upheld. The two complaints investigated via joint agency procedures were provided action plans by the home. The majority of areas detailed in these action plans have been achieved, with the exception of the introduction of a named nurse key worker system and the continued frequency of inconsistent and often inadequate staffing levels. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 16 The remaining two out the seven detailed above concerned dissatisfaction with procedures following the death of a service user and property loss. Both of these were upheld by the home. The Commission have also received a further three complaints regarding insufficient staffing levels and the personal care needs of service users not being met and including a lack of promotion of flexibility, choice and dignity of individual service users. One of these was passed to the provider for investigation in March 2006 (see also staffing section of this report). The other two were raised immediately prior to this inspection, the components of which were assessed during this inspection and are referred to under the various sections of this report. During the inspection, some service users and their relatives advised of ongoing concerns they had raised with regard to staffing levels in the home. There were no records kept in the home in respect of these. The manager conducted a satisfaction survey of residents/relatives in May 2006, which included in its results some concerns regarding inconsistent staffing levels, laundry services and a lack of visible information regarding how to complain. Minutes of a resident/relative meeting of 10 July 2006 detailed that written leaflets regarding detailing information as to how to complain are still needed and that additional staff is still required. There are suitable written procedures and policy guidance provided for staff in the home in relation to recognising abuse and responding to any allegation or suspicion of the abuse of any service user. Staff spoken with were conversant with these and had received training in relation to these. There is also suitable policy and procedural guidance in place in respect of service users monies. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, service users live in a safe and well-maintained environment, which suits their needs and which is decorated and furnished to a high standard. EVIDENCE: Inspection of the private and communal accommodation of those service users’ case tracked was undertaken. All areas of the home seen were well lit and ventilated, safe and warm and provided a high standard of décor, furnishings and fabric. Service users individual rooms were suitably equipped and personalised and expressions of satisfaction were received from many residents and their representatives regarding the standard of furnishings and décor in the home and its cleanliness. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 18 However, concerns were raised by staff regarding the capacity, including insufficient equipment provision in the laundry room, the missing hydraulic hoist as observed during the inspection of one bathroom and also one area of the home where service users bedrooms are located, where the emergency call system is inaudible. The Inspector supports those concerns, which were discussed with the manager during the inspection. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff is not always sufficient to meet service users needs and this together with the failure to always obtain two suitable references for each staff member employed may place service users at risk. EVIDENCE: The arrangements for the recruitment, induction, supervision and training of staff were examined. This included discussions with the manager and staff and also residents and their representatives and examination of associated records, including staff duty rotas. Discussions were also held with the manager and staff regarding residents’ numbers, needs and dependency levels. Discussions with residents and their representatives and staff, examination of complaints records and observations of the organisation and delivery of care over the duration of the inspection indicated that the arrangements for the staffing of the home on a day to day basis was inconsistent and frequently insufficient. Staff duty rotas examined and consideration of resident numbers, needs and dependency levels also reflected this. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 20 Staffing levels impacted considerably on the arrangements for service users personal care, daily living arrangements and individual routines, promotion of choice and independence and some aspects of their health and welfare in respect of medicines administration and nutritional intake resulting in their needs often not being consistently and effectively met. Serious concerns were raised with the registered provider following an inspection of the home in January 2006 regarding insufficient staffing levels. The registered provider provided details of action they intended to take in order to rectify this matter, which were suitable in principle. A further inspection was made to the home in March 2006 and staffing arrangements were found to be satisfactory. Serious concerns were raised again during this inspection regarding staff levels in the home and also separately in writing with the registered provider, whose full response is to be provided. Service user and their representatives stated categorically that staff worked very hard and that they had excellent relationships with them. A total of 51 of care staff were reported to have received at least NVQ level 2 in care. Since the previous inspection for this service, the registered manager had undertaken a training needs analysis for all staff and from this developed a training plan, which was also a required outcome from the two complaints raised and investigated via Derbyshire County Council’s joint agency safeguarding adults procedures. A number of areas of staff training remain outstanding for some staff, including health and safety, pain control, palliative care, diabetes, infection control. A company trainer was due to commence and further training dates were set via a written training plan for October and November 2006 in dementia care, moving and handling and first aid. Pressure area care training and updates had been undertaken during September 2006. All staff have undertaken equality and diversity training. A formal staff induction programme was introduced for care staff in accordance with recognised standards. There were a number of new staff starters who are registered nurses. There were no formal records in place regarding their induction. The personal files of four more recent staff starter were examined. One of these had only one written reference provided, one had none and one, despite having two written references, did not have one from their most recent employer. In all other respects records relating to their recruitment were satisfactory. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 21 An equal opportunities policy is operated and equality and diversity monitoring forms are required to be completed by all prospective staff applicants who may be employed to work at the home. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37, & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Areas of improvement in terms of the management and running of the home are significantly undermined by the lack of effective and consistent quality assurance, monitoring and supervision systems, resulting in the home not being consistently run in the best interests of the service users who live there. EVIDENCE: Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 23 The registered manager is a registered general nurse, who commenced her employment in the home in March 2006. She has recently commenced NVQ level 4 management training. She has a written job description and has is provided with external management support. Satisfaction surveys were sent out to 36 residents/representatives in May 2006, and resident and relative meeting are now in operation. (See also complaints section of this report). There have been a number of areas of changed practise following items raised via these, including the laundry system, a review of menus, equipment and arrangements for meals. There is a clinical lead nurse employed who has undertaken periodic clinical audits in the home. Reports of the monthly visits to the home by a representative of the registered provider are provided in the home. There is no written annual development plan for the home and no total/formal quality assurance system in operation. The arrangements for the management and handling of service users monies were examined and were satisfactory in accordance with the home’s policy guidance. The manager had commenced an operational system of individual care staff supervision in August 2006, although this had not been rolled out to all staff. Not all staff had received appraisal reviews as per the home training plan for 2006 as discussed with the manager and staff. A number of records which are required to be kept in the home were examined during the course of the inspection, including individual needs assessment and care plans of service users case tracked, complaints records, staff records relating to their recruitment, induction, training and supervision, reports of monthly visits by the registered provider, residents monies and safe working practises. These are referred to under the relevant sections of this report and were generally well maintained. The arrangements to ensure safe working practises in the home were examined and discussed with the manager and staff. Some staff had not received training in health and safety or infection control. Details of the required maintenance of equipment in the home were provided by way of the pre-inspection questionnaire and were satisfactory. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 24 The systems and arrangements for the reporting and recording of accidents and untoward incidents were examined by way of case tracking for individual service users which were suitably reported and recorded in accordance with the home’s procedures. Examination of accident records for the months of August, September and October (to date) 2006 averaged a total of 15 accidents to residents per month. The pattern and type of these was discussed with the registered manager and regional manager during the inspection in conjunction with staffing rotas. Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15 Requirement Wherever practicable, service users must be consulted about their care plans, which must made available to and agreed with them. It must be ensured that a clear written care plan is formulated in accordance with any identified/assessed risk(s) to any service user and that this is kept under review. (In this instance with reference to medicines administration relating to one service user case tracked). Medicines must be stored at appropriate room temperatures as appropriate. Records of the administration of medicines to any service user must always be properly made. Medicines instructions must always be followed as specified by staff responsible for their administration. (In this instance with reference to medicines to be taken in conjunction with the specified intake of food). (NMS 12 also applies here). The care home must be conducted so DS0000002046.V316432.R01.S.doc Timescale for action 31/12/06 2. OP7 13 & 15 18/11/06 3. 4. 5. OP9 OP9 OP9 13 13 13 31/12/06 18/11/06 18/11/06 6. OP15 12 19/10/06 Brookview Nursing Home Version 5.2 Page 27 7. OP16 22 8. OP27 18 9. OP29 19 10. OP30 18 as to make proper provision for the health, welfare and supervision of service users and as far as practicable to enable them to make decisions with respect to the care and support they receive. A written copy of the complaints procedure must be supplied to every service user and any person acting on their behalf if that person so requests. At all times, there must be suitably qualified, competent and experienced persons working at the care home in such numbers as are appropriate for the health and welfare of service users. All information and documents must be obtained in respect of any persons working at the care home in accordance with Schedule 2 – in this instance the obtaining of two written references. The registered person must ensure that persons employed to work at the home receive training appropriate to the work they are to perform. (Original timescale 31/07/06). A written record of the induction of registered nurses in the home must be kept for each staff member. 18/12/06 19/10/06 30/11/06 31/12/06 11. OP37 17 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations The registered persons/manager should seek to review the DS0000002046.V316432.R01.S.doc Version 5.2 Page 28 Brookview Nursing Home system for the organisation of care delivery to residents and introduce a named nurse and key worker system. 2. 3. 4. 5. 7. OP9 OP10 OP12 OP15 OP26 Nursing staff should prompt the formal review of medication for any service user on a regular basis or as necessary. Service users dignity should be promoted and maintained at all times. Service users individual rights to make choices in relation to their routines of daily living should be promoted and upheld. The interval between the last snack/meal of the evening the breakfast the following morning should not be more than 12 hours. A rollator iron should be provided in the laundry, together with additional equipment (washing and drying machines) as may be necessary to ensure the efficient operation of the laundry. When obtaining two written references in respect of any person employed in the home, one should be from their most recent employer. The registered persons should implement a formal quality assurance and monitoring system. All care staff should each receive formal supervision at least 6 times per year. 8. 9. 10. OP29 OP33 OP36 Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Brookview Nursing Home DS0000002046.V316432.R01.S.doc Version 5.2 Page 30 - 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!