Inspection on 07/06/05 for Northbrooke House

This inspection was carried out on 7th June 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

Northbrooke House 22/05/07

Northbrooke House 11/10/05

Northbrooke House 11/01/05

Northbrooke House 23/06/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Northbrooke House Main Road Havenstreet Isle of Wight PO33 4DR Lead Inspector Janet Ktomi Unannounced 7th June 2005 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. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Northbrooke House Address Main Road, Havenstreet, Isle of Wight, PO33 4DR 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) 01983 992236 01983 884956 Island Healthcare Ltd Mrs Sally Morrison Care Home 40 Category(ies) of Terminally Ill (2), Old age (40), Dementia - over registration, with number 65 years (8), Physical Disability over 65 years of places (4), Physical Disability (8) Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for long and short term nursing care of the elderly, including two persons under the age of 65 years currently accommodated. Service users in the PD category must be aged 18 and accommodated in the Intermediate Care Unit. Date of last inspection 11/01/2005 Brief Description of the Service: Northbrook House is a registered Nursing Home providing nursing care and accomodation for up to 40 people over the age of 65 years with nursing care needs. The home is an extended converted period house set within its own extensive grounds with panoramic views out across the countryside. The home is located within the village of Havenstreet and is close to bus stops. The limited facilities within the village are within walking distance of the home if required. Service users are accommodated in single bedrooms, all with en-suite facilities, located on two floors accessible to all service users by two passenger lifts. The home has two large communal lounges, two separate dining rooms and employs an activities co-ordinator five days per week.The home has recently completed an extension to provide eight intermediate care beds and additional bedrooms for people requiring longer term nursing care accommodation.The home is owned by Island Healthcare Ltd and managed by Mrs Sally Morrison. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first unannounced inspection of this inspection year, core and additional standards were assessed. Core standards not assessed during this inspection will be assessed during the second unannounced inspection. The inspection lasted six hours during which a full tour of the building was undertaken. Discussions were held with the matron/registered manager, visitors, service users, nurses and staff on duty. Many of the service users living within the home were met during the inspection and those able gave the inspector their views about the service. All the service users stated that they enjoyed living at the home and liked the staff. Care records, staffing records and other records and documentation identified in the report were viewed. What the service does well: What has improved since the last inspection? Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 6 The home has completed the extension to the building and now provides up to forty beds, all within single en-suite rooms. Additional lounge and dining rooms and a second passenger shaft lift have been provided. A private meeting room is now also available. The home is now redecorating and replacing fixtures and fittings within the original part of the building to ensure that all areas of the home are to the same high environmental standard. The home has successfully recruited additional care and nursing staff to meet the increased need following the completion of the home’s extension. 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. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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, 3, 4, 5 and 6. The home provides appropriate information to prospective service users or their representatives. Pre-admission assessments detail service users’ needs and ensure that appropriate people are admitted to the home. Service users admitted for intermediate care are helped to maximise their independence and wherever possible return home. EVIDENCE: The home has a comprehensive service users’ guide that the manager confirmed is provided to all service users or their representatives prior to admission. The guide contains all the relevant information required in the National Minimum Standards. The home is currently producing a specific information guide for the intermediate care service users that will be assessed during the next unannounced inspection. At present the service users’ guide, minus the information about fees and contract details, may be provided to intermediate service users. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 9 The pre-admission assessments and care plans for recent admissions were viewed during the inspection. These indicated that potential residents and intermediate care service users were fully assessed prior to admission and that this information was then used to formulate care plans. Assessments were based on a standardised format that covers all the relevant areas identified in the standards and includes specific assessments in relation to manual handling, nutrition and pressure area needs. Discussions with the manager indicated that she would clarify information from the intermediate care nurses should their assessment be unclear as to whether the home would be able to meet the needs of the intermediate care service users. Care and nursing staff stated to the inspector that they felt able to meet the needs of existing residents and that appropriate numbers of staff are employed to ensure needs are promptly met. Due to the level of disability it was not possible to talk with all residents, however during a tour of the building many of the service users were seen and all appeared happy and well cared for. Service users spoken with stated that they felt their needs were met and that appropriate numbers of care staff are employed at the home. External professionals visiting the home at the time of the unannounced inspection informed the inspector that they felt the home appropriately met service users’ needs. The home has a variety of manual handling and pressure relieving equipment that was seen during the inspection. During the unannounced inspection the manager was organising training via specialists at St Mary’s hospital in respect of PEG feeding to ensure that care needs of a newly admitted resident would be fully met. Due to the level of disability and complex health needs of people admitted to the nursing home for either intermediate or long term care it is usually not possible for them to visit the home prior to admission. The manager stated that she encourages potential service users and service users’ relatives to visit the home wherever possible. The inspector was able to speak with one person who had transferred from intermediate care to long term nursing care. This lady confirmed that she had been involved in the decisions, had been able to select a large room which had been redecorated to her style and that items of her own furniture had been brought to the nursing home. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 and 10. All long term and intermediate care service users have individual care plans detailing how health, personal and social needs will be met. Care plans indicated and visitors, service users and staff spoken with confirmed that health needs are met, that staff treat service users with respect and that privacy is upheld. EVIDENCE: During the unannounced inspection a number of resident and intermediate care service user care plans were viewed. All service users have individual care plans compiled from information gained during pre-admission assessments and updated by named nurses, generally monthly and if care needs change. The care plan details the nursing and care the service user requires to ensure all aspects of health, personal and social care needs are met. Care plans are preformatted with individualised hand written additions where appropriate. Within the care plans are information and risk assessments to cover moving and handling, pressure areas, falls and nutritional needs. Service users spoken with were generally aware that written records and care plans are held by the home although due to cognitive limitations not all service users are able to participate in planning their care. The manager stated that where this is the Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 11 case family members or representatives are involved in care planning. At the time of the unannounced inspection the manager stated that one service user had pressure injuries developed in the home with three other service users having been admitted to the home with pressure injuries from St Mary’s hospital. Care plans contained updated Waterlow assessment and pressure area management plans for all service users for whom assessment had indicated a need. During a tour of the building pressure relieving equipment was seen in use around the home. The home employs an activities coordinator who explained to the inspector her role and how she tries to provide group or individual activities suitable for all service users. Visiting professionals confirmed to the inspector that they believed the home meets the health and social care needs of the service users. During the inspection care and nursing staff were observed knocking on service users’ doors and to treat people with respect. Visitors and service users confirmed this to be the case, stating that the home’s staff are pleasant and helpful. Comment cards returned to the CSCI by service users or their relatives all stated that staff were polite and friendly and that privacy and dignity are respected at all times. Discussions with nursing and care staff indicated that they view service users as individuals and that care practises are not task oriented but individually undertaken. The training co-ordinator confirmed that new staff are instructed during their induction period as to how to appropriately treat service users with respect at all times. All bedrooms are for single occupancy ensuring personal care or medical consultations/treatment are provided in private at all times. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 and 15. The home meets service users’ social and leisure activities in a flexible and varied manner. Contact with family and friends is encouraged and supported and a varied, nutritious diet is provided which meets individual needs. Service users are provided with opportunities to make choices and to have control over their lives. EVIDENCE: The pre-admission assessments seen included information about service users’ social and leisure interests and this is included in care plans. The home employs an activities co-ordinator who is developing her role within the home and works five days per week. Service users are able to make choices about aspects of their lives including meals, where they spend their time and whether they join in activities or not. The home has two lounges, one within the traditional nursing home and a separate intermediate care lounge. There is also a pleasant patio and path around the outside of the home with level access from the home. The inspectors were able to meet with some visitors during the unannounced inspection who confirmed that they are welcomed to the home and able to visit at any reasonable time. Service users confirmed that they are able to have visitors and the home has a small room available should people wish to visit in private other than in service users’ bedrooms. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 13 Information about visitors is included in the service users’ guide and additional information provided at the time of admission. Residents and visitors spoken with during the inspection were positive about the food they receive at the home. Service users reported that they have a choice at all meals that may be taken wherever they wish, within their own rooms, the dining rooms or one of the lounges. The inspector was able to see care staff completing menus with service users as to their choice for their evening meal. Menus seen provided a choice of different main meals with the chef confirming that fresh fruit and vegetables are used whenever possible. Discussions with the chef and kitchen assistants confirmed that consideration is given to variety in meals and ensuring service users enjoy their meals. Meals served during the inspection were well presented and had appropriate portion sizes. On admission a food sheet is completed detailing individual likes and dislikes as well as special dietary requirements. Special diets and requests were catered for appropriately. Service users confirmed that they have access to snacks and hot and cold drinks in between meals and these were seen within the lounges around the home. Support is required by some service users and was seen to be provided in an unhurried, discreet manner. All required records were in place and are compliant with the regulations. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 and 18. Service users or their representatives are able to complain if they are unhappy with the service provided at the home. Staff are aware of adult protection issues and would respond appropriately if they had concerns in relation to adult protection. EVIDENCE: The home provides service users with information as to how to make a complaint within the service users’ information and on the hall wall. The home’s complaints policy and procedure fully complies with the requirements of the National Minimum Standards. Information as to how to complain via the Commission for Social Care Inspection is included in the service users’ information. The home maintains a record of complaints, no complaints had been received since the previous inspection. Discussions with service users and visitors indicated that they felt able to complain and indicated that they would do so to either the manager or administrator. Care and nursing staff spoken with during the inspection were aware of what they should do if a service user or relative wished to complain. At the time of the unannounced inspection service users’ only complaints were in respect to problems with the call bell system. A new system using radio waves had been installed on completion of the new wing to the home. This has proved unsatisfactory and the manager has given the manufacturer two weeks to resolve the problems or remove the system and an alternative will be fitted. The inspector was able to meet the home’s external training co-ordinator who showed the inspector a copy of the induction for care and nursing staff. The home has all the relevant policies in respect of adult protection including whistle blowing and gifts to staff. These relate to the Isle of Wight adult Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 15 protection policy. Care and nursing staff undertake training about adult protection during both their induction period and a yearly update session. Care and nursing staff were aware of adult protection issues and correctly identified the action they should take should they suspect that an adult protection issue has occurred. The home has a full and comprehensive recruitment procedure that should ensure that unsuitable people are not employed in the home. Care plans were seen to contain risk assessments and management plans for individuals whose behaviour may be challenging to staff or behaviours which may place the service user at high risk. The home does not become involved in service users money and any additional expenses such as chiropody or hairdressing are invoiced to the service user or their representative on a monthly basis. Service users all stated that they felt safe at the home and that staff were kind and considerate. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 and 26. The home is warm, clean and well maintained providing appropriate accommodation, both private and communal, to meet service users needs. EVIDENCE: The premises have operated as a care home for a number of years and over time has been adapted to meet the needs of the client groups accommodated. A new extension providing additional en-suite bedrooms, lounge, dining room and assisted bathroom as well as a second shaft lift has recently been completed and is now in use providing accommodation to a high standard. The home itself is well maintained with an ongoing maintenance programme. At the time of the unannounced inspection there was redecoration work being undertaken in the hall of the original part of the home. The manager explained that bedrooms are redecorated before new long term service users move into them. One service user who had moved from intermediate care to long term nursing care informed the inspector that she had chosen her room and that it had been redecorated to her colour choices prior to her moving into that room. This service user also informed the inspector that she had been able to bring items of her own furniture into the home. The home employs a maintenance Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 17 man who completes routine jobs within the home and gardens. The inspector was able to meet him during the inspection. Externally the gardens are well maintained providing pleasant areas accessible to service users. There is car parking available at the front of the building. There continues to be some residue external work following the recent completion of the extension and the inspector was able to see workmen completing tasks in the car park and providing a slope path to the lawn from the patio. During the unannounced inspection a full tour of the home was undertaken, service users private accommodation (bedrooms) and communal areas are appropriately furnished and the home was warm, clean and tidy with no offensive odours noted. Service users and visitors confirmed that the home is always clean and warm. All bedrooms are for single occupancy. Service users stated they were happy with the facilities provided at the home. The home provides service users with two lounge areas, two dining rooms and also has a small private room that could be made available for people to receive visitors in private other than in their bedrooms. All communal areas are located on the ground floor and assessable to all service users. Lighting and furnishings within communal areas are domestic in nature and appropriate for service users. An area inside the porch entrance to the patio has been designated as the only area that service users may smoke. The manager confirmed that all equipment has regular servicing contacts and is fully maintained. Individual referrals are made to Occupational Therapists for specific pieces of equipment when a need is identified. All bedrooms, bathrooms, WC’s and communal areas have call bells linked to a central system. The manager explained that they have experienced problems with the new call bell system and the manufacturer is now involved in rectifying the situation and an alternative arrangement may be considered. The home employs domestic staff responsible for all hygiene and cleanliness issues. On the day of the unannounced inspection the home was found to be clean, tidy and free from offensive odours. All WC’s and communal bathing facilities were noted to have a supply of paper towels and liquid soap with guidelines available for staff around infection control and the use of chemical cleaners. Care staff informed the inspector that supplies of gloves and paper towels are freely available. The staff, training coodinator and manager confirmed that all nursing, care and domestic staff receive training in infection control. The home has a laundry with industrial machines capable of washing to required temperatures. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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, 28, 29 and 30. The home employs appropriate numbers of registered nurses, care staff and ancillary staff to meet the needs of service users. A comprehensive recruitment, induction and training programme should ensure that unsuitable people do not wok in the home and staff have the necessary skills required to meet service users needs. EVIDENCE: The Department of Health has yet to publish staffing guidelines for Nursing Homes. Staffing rotas confirmed the manager’s opinion that the home provides sufficient staff numbers to meet the needs of service users. The home employs five care staff and two qualified nurse during the morning, four care and two nurse during the afternoon and three care and one nurse overnight. In addition to the qualified nurses and care staff employed the home also employs a manager, catering, domestic, maintenance and administrative support staff. Service users and visitors spoken with during the inspection reported that they felt care staff had sufficient time to meet their needs. Staffing rotas seen during the inspection confirmed the manager’s statement concerning staffing numbers. Care and nursing staff stated that there were adequate numbers of staff employed at the home to meet service users needs and that every body worked together as a team. Staff confirmed that they cover extra shifts required due to sickness or holidays. Discussions with the manager indicated that she would consider the staffing levels available when making a decision Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 19 about new admissions of service users and had delayed using all the new beds created by the extension until the home had enough care staff to meet their needs. All potential employees complete an application form, involving full work history, two written references (checked by telephone), recorded interview by two people, Criminal Records enhanced level and POVA check, NMC, health declaration and trial shifts. All new employees have a three month probationary period, full induction programme and terms and conditions of employment. The records in respect of the more recently appointed staff and a number of others were seen during the unannounced inspection and corresponded to the process described above. In the case of qualified nurses their PIN numbers and registration details are confirmed with the NMC. The staff handbook provided to all staff was available for the inspectors and contained all the relevant information and essential policies new staff require. The home employs an independent training co odinator who was present in the home at the time of the unannounced inspection. The inspector was able to spend some time with her prior to a planned training session. The induction process for new care and nursing staff was seen as were training records held by the co odinator. The induction training meets National Training Workforce targets and includes the allocation of a mentor, supervised practise and reflective accounts. Care staff are expected to complete the induction booklet within six weeks and the foundation within three months although some flexibility for part time staff is permitted. Specific induction training is also provided for nursing, catering and domestic staff. The home currently has thirty-three percent of care staff qualified to at least NVQ level 2 with an additional two care staff undertaking NVQ level 2. The home employs adaption nurses as care staff until they have completed their training and received PIN numbers to work as qualified nurses. Newly appointed care staff confirmed the recruitment and induction process as did a member of care staff who works as a mentor for new care staff. All staff undertake initial and update training in all mandatory subjects, health and safety, food hygiene, manual handling, fire awareness, infection control and adult protection. Two of the qualified nurses have completed training to allow them to take blood specimens from service users and the manager was overheard arranging specific training with a hospital specialist to ensure that the needs of a new service user could be fully met. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 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, 35 and 37. The management arrangements within the home ensure that service users needs continue to be met and creates a homely atmosphere in which service users fell valued and well cared for. The home must ensure that regular checks of emergency lighting are undertaken and recorded. EVIDENCE: The manager has worked at the home for over twelve years and managed it for the past four years. The manager is a Registered General Nurse who has completed the NVQ level four in management and has a certificate in Health and Social studies. The manager stated, and training records confirmed, that she has completed relevant update training to meet NMC prep requirements. In addition the manager holds D32/33 and is an NVQ assessor. The manager has an appropriate job description and there are clear lines of accountability within the home. The home has two deputy managers each responsible for a part of the home who assist the manager in the day to day running of the home and ensure care needs of service users are identified and met. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 21 The home has the required insurance certificates. As previosly stated the home does not become involved in managing individual service users personal finances. Additional expenditure such as that for newspapers, hairdressing and chiropody are invoiced monthly to service users or their representatives. During the unannounced inspection a variety of records were inspected. These included, pre-admission assessments, care plans, risk assessments, care records, staffing rotas, recruitment and staff files, menus and food records, fire and emergency lighting equipment records. All were found to be well maintained and appropriately stored. The emergency lighting checks had not been undertaken as frequently as is required. The manager had previously undertaken these checks herself, however since the completion of the extension this will now take an extended time and she is to consider arranging for these to be undertaken by the maintainence man. It is required that procedure is introduced to ensure that emergency lighting checks are undertaken. Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 x x x 3 x 2 x Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 23 no 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 37 Regulation 21 (1) Requirement Emergency lighting must be checked at regular intervals. Timescale for action immediate 8-6-05 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 Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 24 Commission for Social Care Inspection Mill Court Furrlongs Newport PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Northbrooke House H55H04_S12563_Northbrooke House_V218306_070605 Stage 0.doc Version 1.30 Page 25 - 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!