Inspection on 25/07/05 for George Brooker House

This inspection was carried out on 25th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

George Brooker House 23/05/07

George Brooker House 20/07/06

George Brooker House 09/11/05

George Brooker House 10/02/05

George Brooker House 16/09/04

George Brooker House 11/02/04

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

CARE HOMES FOR OLDER PEOPLE George Brooker House 100 Dagenham Road Dagenham Essex RM9 6LH Lead Inspector Edi OFarrell Unannounced Inspection 25 July 2005 10:30 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 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. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service George Brooker House Address 100 Dagenham Avenue, Dagenham, Essex RM9 6LH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 984 8983 0208 592 0119 Abbeyfield East London Extra Care Society Limited Janet Evans Care Home 43 Category(ies) of DE(E) Dementia - over 65 (30) registration, with number OP Old Age (13) of places George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10 February 2005 Brief Description of the Service: George Brooker House provides accomodation, support, and personal care for 43 older people. The home is operated by The East London Extra Care Society, which is a member of the National Abbeyfield Society. The home is purpose built, and is situated on the edge of parkland, a short walk from Dagenham Heathway, which has both tube and bus routes. All bedrooms are single, with 19 having ensuite facilities. The home is currently divided into two units; a ten bed unit specifically for dementia care, and a 33 bed unit with 20 places for people with dementia and 13 for frail older people. The dementia care unit is on the ground floor with access to an attractive enclosed garden. The larger unit has a ground and first floor, which can be accessed by lift or stairs. Personal care is provided on a 24 hour basis, with health needs being met by visiting professionals, or by staff accompanying service users to hospital appointments. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place from mid morning to early evening on a weekday. The whole of the building was toured, both inside and out, and this included entering some bedrooms. Some service users were asked for their views and experience of living in the home. Whilst many were unable to comment due to their level of disability, those who were able were very complementary. Some staff were also asked for their views, and the Chair of the Management Committee, who was in the home during the inspection, was also spoken to. Service users, staff and management are thanked for their input to the inspection. Sixteen Requirements and two Recommendations set at the two previous inspections on 16/09/04, and 10/02/05 were checked. Due to a delay in the Commission sending out the draft report of the September ’04 inspection the home had not received it before the February ’05 visit, and they have, as yet, still not received the final version of the February report. These factors have been taken into account when setting Requirements and Recommendation in this report. A separate specialist pharmacist inspection was carried out in April 2005 when 18 Requirements were set, these were also checked during this visit. What the service does well: Information about the home is written in plain English, which helps prospective service users and their relatives to make informed choices when they are thinking of moving into the home. There is a very warm relationship between staff and service users and the home is run with the needs and wishes of the service users in mind. Health, personal care, and social needs are identified and written down in care plans. All bedrooms are single, and service users are encouraged to have personal possessions on display, including small items of furniture. There is a homely atmosphere and attention to detail in furniture, fixtures and fitting, and decoration, for example staff have decorated some of the bathrooms with friezes, which makes them look domestic in nature. The home is very clean. Activities, both within and outside the home, are given a very high priority, and are planned imaginatively. As recent research has shown that keeping active is a major factor in older people remaining physically and psychologically well the home is to be commended for this. There is a varied and well-balanced menu, with plenty of choice, and the food is well cooked and presented. Attention to detail is again demonstrated by dining tables being set with attractive table settings. The catering staff spend time with the service users getting to know their likes and dislikes, and work in collaboration with the care staff to make sure that all nutritional needs are met. Staff were observed to relate well to service users and to understand and respect their wishes. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 & 5 Prospective service users, and their relatives, have the information they need to make an informed choice about where to live. They have an opportunity to visit the home and assess the quality and facilities, and know that it will meet their needs. Some service users have a written contract/statement of terms and conditions, but others still have not, despite this having been a Requirement at the previous inspection, and being a Regulation that all homes have to adhere to. EVIDENCE: The Statement of Purpose and the Service User Guide are available in the entrance hall. These are well written, using plain English. Prospective service users, and their relatives/friends, are encouraged to visit the home, and to talk to service users, visitors and staff about the service. The home has a standard format for assessing prospective service users that is comprehensive, and the information from this is used to develop initial care plans. This means that the care staff are aware of needs and how to meet them at the stage of admission. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 9 In response to a Requirement set at previous inspections contracts have been issued to all new service users, and some were seen in the case files that were examined. The manager reported that these were mainly for new admissions, and that contracts for all other service users had been given to the relatives for signing, and that they have not yet all been returned. She also stated that the contract did not seem to be applicable to the long-standing residents. On examining a specimen contract the only section that was found not to be applicable to this group was that which covers the trial period. Individual contracts are required by the Care Homes Regulations 2001, and all service users must have one in place by the new deadline set in Requirement 1. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 & 10 Service user’s health, personal and social care needs are set out in an individual plan of care, but these are not all being regularly and systematically reviewed. Their needs are being met on a day-to-day basis, but the recording systems need to be improved. In response to Requirements set at previous inspections some changes have been made to the policy, procedure and practice for dealing with medicines, but some further changes are needed. Service users are treated with respect and have their right to privacy upheld. EVIDENCE: Four care plans were examined and discussed with the manager, a unit manager, and the Chair of the Management Committee. The four service users were spoken to, but due to the level of disability of three, they were unable to give their views. Comprehensive care plans are in place, and in the four plans examined they covered all aspects of care that were observed to be needed by each service user. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 11 Some of the care plans had been reviewed, but these were mainly in response to changes in need, rather than being part of a systematic care planning system. In addition a new risk assessment format has recently been introduced, so it is unclear in some care plans which document is current. Following discussion it was agreed that the managers would audit all the care plans in order to ensure that they provide a comprehensive, up-to-date, working document for carers to follow on a daily basis. This is Requirement 2. Health needs were also covered and addressed by referral to the GP, District Nurse, or other health specialists. In one case, the need for referral to a Consultant had been identified in February ’05, but not yet achieved. The unit manager and the manager of the home were able to provide information about their attempts to follow this up, but there were no written records. It is important that the home is able to demonstrate that every effort has been made to make sure that all health needs are met, and all such attempts must be documented. This is Requirement 3. The Commission carried out a specialist pharmacist inspection in April 2005, and the Requirements set at that inspection were checked during this visit, along with one Requirement and one Recommendation set at previous inspections. The vast majority were met, but two remain outstanding; these were discussed with a unit manager and the manager of the home and are covered by Requirement 4. The records of the quarterly meetings of the relatives dated 14/06/05 made reference to a relative informing those present that the wrong quantities of medicine had been given. As the manager does not attend these meetings, and had not read the record until the inspection, she was not aware of this statement, as no relative had reported it to her. The manager must investigate this alleged incident and forward a report to the Commission. This is Requirement 5. During the visit staff were observed carrying out their duties, which included personal care, social activities, assisting with eating, and dealing with different behaviours associated with dementia and ageing. All the staff on duty during the inspection were noted to treat service users with respect, and to give privacy and dignity a high priority. Those service users who were able to state their views said that the staff were ‘wonderful’ and ‘can’t be beaten’. This applied not just to the care staff but to all types of staff employed at the home. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15 & 16 The home is to be commended for the high priority that is given to maintaining each service user’s previous lifestyle, and to encouraging new interests. Contact with family, friends and the local community is encouraged, and social events are organised on a regular basis. Staff help service users to exercise choice and control over their lives. Service users receive a wholesome, appealing, and balanced diet, and both care and catering staff make every effort is made to ensure that all nutritional needs are met on a daily basis. EVIDENCE: The home employs an activity co-ordinator, who, in conjunction with care staff, organises a range of activities, both in and outside of the home. The daily logs of ten service users were examined, and each had records of such activities, for both weekdays and weekends. These included individuals being taken out for walks, quizzes, bingo, visits to theatres, boat trips, and an art group. The latter was held on the morning of the inspection, and produced some impressive pictures, which were framed by early afternoon, ready to be put up in the corridors. Information about future events, some of which double as both fundraising and activities was prominently displayed. Five service users had visited Hedingham Castle the previous day, when pictures to record the George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 13 event had been taken. There had also been a birthday party for one service user, and the balloons and cake were still evident. A score of 4, commendable, has been given in recognition of the excellent work that the activity co-ordinator and other staff do in maintaining service users’ interests, and stimulating new ones. The assessments and care plans clearly stated likes and dislikes, and how each service user prefers to be approached, including what name they wish to be called by. During the visit staff were observed to relate well to service users, to understand their wishes, and to respect them. The service users who could express a view described their lifestyle, and how it suited their needs. The menu was examined and discussed with the catering staff, and lunch and supper was observed being served. The catering service is contracted from a commercial catering company. The menu is varied, with at least two choices at every meal. The catering staff spend time getting to know the service users and their preferences, as well as the care staff passing on information to them about changing need. An example was at suppertime where one service user is currently feeling very indecisive about what they want to eat, so all three options were provided. The provision of culturally appropriate food, for example if a person from a specific Asian or Jewish background was to be admitted, was discussed with the chef. He reported that there were personnel within his organisation who would be able to provide appropriate advice. The meals are well presented, and attention to detail is evident in the use of attractive table settings. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 standard(s) 16, 17 & 18 Service users and their relatives can be confident that their complaints are taken seriously if they follow the formal procedure. If other routes, such as the relative’s group, are used to raise complaints this may not always be the case. Service users’ legal rights are protected. The management of the home has acted on Requirements set at previous inspections by arranging training on adult protection, and obtaining each placing authorities policies and procedures. Care staff are aware of their responsibilities in relation to adult protection, but training specific to managers is required. Managers are not always informing/seeking advice from relevant agencies in relation to significant events, such as adult protection issues. EVIDENCE: The record of complaints was examined, and where relatives had put in formal complaints there was evidence that the manager had taken this seriously by investigating and responding in writing. Due to the level of disability of many of the service users their relatives are often acting as advocates, so it is important that all avenues of information are fully used by managers. The relatives’ group meets four times a year, but is not attended by the manager of the home. This is unusual, as in most homes relatives’ groups/meetings are generally management lead, as one part of a quality monitoring/assurance process. The situation was discussed with the current manager, who leaves shortly, and the person who is going to be the manager. The latter gave a George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 15 commitment to attending all future meetings, and to dealing with any complaints that are raised via this source. This is Requirement 6. Money held by the home on behalf of service users was checked on a random basis, and was correct. The home keeps comprehensive records of all such monies. At the last inspection two Requirements were set in relation to adult protection and both have been met. Staff have attended training, and the home now has copies of all placing authorities policies and procedures. Staff who have not yet been on the training are booked on courses later this year. The care staff spoken to during the visit were very clear about their responsibility to report all potential abuse, and have demonstrated a commitment to this in the past. Two adult protection investigations were on-going at the last inspection, and some issues remain outstanding which the Commission will follow up with the Local Authority and the management committee. In examining the record of complaints there was one that should have been referred to both adult protection and to the Commission, and this did not happen. This is particularly concerning because both the Commission and the Local Authority have previously raised concerns about the way that managers deal with adult protection procedures within this home. All staff with managerial responsibility must have appropriate training in being able to identify what might be abuse, including service user to service user abuse. They must know who they must inform and seek advice from in all suspected cases of potential abuse. This is Requirement 7. Under the Care Homes Regulations the home has to inform the Commission of significant events, this is an important part of our monitoring of homes. This home has been informing us when service users die, but not about other events such as serious falls resulting in fracture, and all admissions to hospital. Because this home does not provide nursing care they should also inform us about serious illness. This is Requirement 8. This was discussed, by phone, with one of the unit managers prior to the inspection, so has not been set as an Immediate Requirement. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25 & 26 Service users live in a homely, safe, and comfortable environment, where both communal and individual bedrooms meet their needs. Management has responded to Requirements set at previous inspections, and have funded plans to make further improvements to the home. The home is clean, pleasant, and hygienic. EVIDENCE: The visit started at 10.30 a.m. on a Monday morning with a tour of the building. Bedrooms were either entered, or seen from the corridors, and all bathrooms and communal toilets were entered. All lounges and dining areas were seen, as were the gardens and outdoor sitting areas. The standard of cleanliness was high, even where areas had not yet been cleaned that day, such as some bedrooms where beds were still unmade. There were no offensive odours noted during the seven hours of the visit. All bathrooms have assisted baths, and staff have painted friezes on the walls in order to make the rooms more homely. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 17 The carpets to the large lounge on the ground floor and the stairs are going to be replaced, the area decorated, and new chairs have been ordered. Specialist equipment such as hoists are in place where needed, and all areas have full disabled access. The use of the communal space on the ground floor of the larger unit has recently been reorganised. What were separate lounge and dining areas have been changed to combined lounge/diners. This is in order to facilitate service users being worked with in smaller groups. There have also been discussions about possible structural changes to these areas for the same reason. These changes remain subject to debate. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 The numbers and skill mix of staff meet service users’ needs. They are supported and protected by the home’s recruitment policy and practice. Staff are trained and competent to do their jobs. EVIDENCE: Staff were observed on both the morning and afternoon shift, and some were asked about their work within the home. Four care plans and ten daily logs were examined. The staff demonstrated knowledge of the needs of the individual service users, and of older people in general, including dementia. They were observed using distraction as a method of managing difficult behaviour, using low voice tone to settle agitation, and working on activities with individuals. Four recruitment files were checked, these were of people interviewed since the last inspection. As all checks have not been completed none of these people have yet started work. There was evidence that full checks are being carried out, including the manager asking for a third reference, where both were from the same employer. The home has an on-going programme of staff training, and these records were checked. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 34, 35, 35 & 36 The people responsible for the management of the home have not been discharging all their responsibilities fully during recent months. Service users are safeguarded by the financial procedure of the home. Staff are not receiving the level of formal supervision that is required by the National Minimum Standards. EVIDENCE: Since the last inspection the Chair of the management committee has resigned and a new one has been elected. The previous Chair was designated the ‘Responsible Individual’ (RI) for the purposes of the organisation fulfilling duties under the Care Standards Act 2000. The RI has a specific responsibility to ensure that they, or, under certain circumstances, another designated person, visits the home on a monthly basis in order to form an opinion of the standard of care provided. They must then prepare a written report and George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 20 forward a copy to the Commission, the registered manager, and other committee members. The RI is always a named person, as opposed to being connected to a post. The Commission has to be satisfied, by taking up checks, that they are a ‘fit’ person under the terms of the Act. Since the resignation of the previous Chair the home has had no RI so the monthly visits have not been carried out. The Commission wrote to the secretary to the Trustees on 28 April 2005 requesting that the committee nominate a person for the RI role. Further letters were sent on 12 May 2005, and 14 June 2005. The new Chair has now been nominated as the RI. The Commission will be meeting with the RI and home manager in the near future to ensure that Requirement 9 is, in future, met. Please refer to Regulation 26 of the Care Homes Regulations 2001 for details of the responsibilities of the RI. As stated above under the section on complaints and protection the responsible persons (Registered Manager and RI) must inform the Commission about all significant events but this has not been happening. Please refer to Requirement 8 and Regulation 37 of the Care Homes Regulations 2001. The two types of reports have a dual purpose of assisting the organisation and the manager to monitor the service and assess quality, and of keeping the Commission informed between inspection visits. Trends, such as falls in certain areas of the building or at certain times of day, can often be picked up on via the Regulation 37 notifications. The Regulation 26 visits and reports can often help organisations to identify problems internally and take remedial action, thereby improving the service. The lack of both is of concern to the Commission who will be following these up with the Chair and home’s manager. The home is currently going through a period of change in management as the current Registered Manager leaves in early August. The new manager has applied for registration with the Commission, and this will be processed over the coming weeks. Staff supervision records were checked, and whilst some have taken place and were well recorded the home is not meeting the standard for formal supervision for all care staff at least six times per year. This has been a Requirement at the last two inspections and has been brought forward as Requirement 10, with a new timescale, which must be adhered to. The registered persons must be able to demonstrate within this timescale that they are meeting Standard 36. George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 1 2 x x 3 3 2 x x George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 22 YES 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 OP2 Regulation 5 (1) c Requirement The registered persons must ensure that each service user is provided with a contract/statement of terms and conditions. Previous timescale of 10/05/05 not met. Service user care plans and risk assessments must be reviewed on a regular basis. Previous timescale of 10/03/05 not met. An audit of the current documents must be carried out so as to ensure that they are comprehensive, up-to-date, and provide a useful working document for care staff to use. Daily records made about service users must be consistent and written on a daily basis. Previous timescale of 11/02/05 not met. Where referral is being made to health professionals full records must be maintained. The registered persons must ensure that all Requirements set by the specialist pharmacist inspector are fully met. The registered manager must investigate the alleged mistake in medication administration, and forward a report to the Timescale for action 30/09/05 2. OP7 12, 15 & 17 30/09/05 3. OP7 & OP8 12, 15 & 17 31/08/05 4. OP9 13 (2) 31/08/05 5. OP9 13 (2) 31/08/05 George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 23 Commission. 6. OP16 22 The registered persons must ensure that all complaints, from whatever source, are investigated and reported on. A comprehensive log of all complaints, including the outcome of investigations must be maintained. The responsible persons must ensure that all management staff have enough knowledge and understanding of adult protection policy and procedure to know when to report/seek advice from external agencies such as the police, the Commission and the Local Authority. If necessary a specific training course for managers must be arranged. The responsible persons must inform the Commission, without delay, of all significant events in line with all aspects of Regulation 37. The Responsible Individual must visit the home on a monthly basis in order to form an opinion of the standard of care. They must produce a written report and supply a copy to the Commission, the Registered Manager, and to other committee members. The Registered Persons must ensure that appropriate supervision arrangements are put in place and the written evidence is available to confirm this. Previous timescale of 10/03/05 not met 31/08/05 7. OP18 13 (6) & 18 (1) (a) 31/10/05 8. OP18 & OP31 18 & 37 31/08/05 9. OP31 26 31/08/05 10. OP36 18 (2) 31/10/05 George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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 Good Practice Recommendations George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 George Brooker House G55_S0000027918_George Brooker_V240425_250705_Stage 4.doc Version 1.40 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. 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!