Care Home: Brook House

What has improved since the last inspection? Throughout this inspection there were vast improvements noted, and we are confident these will continue. The Medication records were in order, contained the required entries and had been signed appropriately by staff. Pre Admission documentation was in place, and was being completed appropriately. The home is now addressing any deterioration of resident`s conditions through review meetings and consultants appointments in order to proactively identify, any areas of care, that this home may not be able to manage.Brook HouseDS0000014887.V374820.R01.S.doc Version 5.2 Page 7Since the last inspection the manager has rearranged the communal areas to provide a more spacious dining area, and a smaller second lounge. All areas have sufficient space to accommodate the residents comfortably. The conservatory is now being used as an area for staff to have their breaks. Supervision of staff is now divided between the manager, her deputy and the senior carer, and all the files that we looked at identified that the staff are receiving supervision at least once every two months, sometimes more frequently. Regulation 26 visits are being carried out monthly by the manager of a neighbouring care home. This is proving very beneficial and the manager says it gives a clear vision of areas where further improvement can be made. What the care home could do better: Risk assessments for issues such as falls, nutrition and dependency levels were in place in the files, however they were not always reflective of, or reflected in the care plans. Key inspection report CARE HOMES FOR OLDER PEOPLE Brook House 72 High Street Riseley Bedfordshire MK44 1DT Lead Inspector Mrs Louise Trainor Unannounced Inspection 5th May 2009 10:00 DS0000014887.V374820.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook House Address 72 High Street Riseley Bedfordshire MK44 1DT 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) 01234 708077 01234 709712 lesleyh@gotadsl.co.uk Riseley Beds Limited Mrs Lesley Atkinson Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Physical disability over 65 years of age (20) Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is permitted to accommodate one named service user (Variation V26762) in the category of DE from 01 December 2005 up to their discharge from the home. 15th July 2008 Date of last inspection Brief Description of the Service: Brook House is a listed building located in the village of Riseley in North Bedfordshire. The building was extended during 1995 and now provides accommodation for up to 20 older people. The ground floor is split level the lower part housing two communal areas and the higher level some bedrooms a dining room, kitchen, laundry, bathing and toilet facilities. Access to the top floor of the home is via a staircase fitted with a stair-lift, the remaining bedrooms, bathrooms and toilets are located on this floor. A day care facility for the use of residents and people in the surrounding area is available in an adjacent building. Car parking spaces for several vehicles is available to the front and side of the home. To the rear of the building is a raised garden that is accessed via a slope. The statement of purpose for the home identifies that the home is unable to accommodate residents who are unable to manage the stairs, which connect the split-level lower floors. The fees for this home have recently been reviewed and are now ranging from £454.00 to 495.00 per week. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection this year for Brook House. It was carried out on the 5th of May 2009, by Regulatory Inspector Mrs Louise Trainor, between the hours of 10:00 and 14:30 hours. The homes manager was present throughout the inspection, and feedback was given both during, and on completion of this inspection. During this inspection we tracked the care of two people who live in this home. This involved reading their records and comparing what was documented, to the care that was being provided. We also looked at the pre admission work that had been done for two people who had been admitted to the home since the previous inspection. Documentation and records relating to: staff recruitment, training and supervision, medication administration, complaints, quality assurance and health and safety in the home were also examined. We spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this four and a half hour inspection. A tour of the premises also took place. We would like to thank everyone involved for their support and assistance during this visit to the home. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 6 What the service does well: Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. The home understands the importance of having enough information when choosing a care home. The manager has the required qualifications and experience to run this home. She is working continuously to make improvements to systems that may improve the lives of the people who live there. The service has a strong commitment to ensuring residents maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and individual’s are assisted and supported to make personal choices. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. This home provides a clean, comfortable and homely environment for the people who live here. Individual rooms are furnished with personal possessions that reflect their personal life history. This service recognizes the importance of training and delivers a programme that exceeds the National Minimum Standards. Recruitment procedures are fully adhered to so that residents are protected. What has improved since the last inspection? Throughout this inspection there were vast improvements noted, and we are confident these will continue. The Medication records were in order, contained the required entries and had been signed appropriately by staff. Pre Admission documentation was in place, and was being completed appropriately. The home is now addressing any deterioration of resident’s conditions through review meetings and consultants appointments in order to proactively identify, any areas of care, that this home may not be able to manage. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 7 Since the last inspection the manager has rearranged the communal areas to provide a more spacious dining area, and a smaller second lounge. All areas have sufficient space to accommodate the residents comfortably. The conservatory is now being used as an area for staff to have their breaks. Supervision of staff is now divided between the manager, her deputy and the senior carer, and all the files that we looked at identified that the staff are receiving supervision at least once every two months, sometimes more frequently. Regulation 26 visits are being carried out monthly by the manager of a neighbouring care home. This is proving very beneficial and the manager says it gives a clear vision of areas where further improvement can be made. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 8 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 Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 People using the service experience good quality outcomes in this area. The home understands the importance of having enough information when choosing a care home. Pre Admission documentation was in place, and was being completed appropriately. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has a Statement of Purpose and a Service User Guide that are held electronically and reviewed on a regular basis, so that information is always correct when it is issued to new or prospective residents. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 10 People who are considering living in this home, are encouraged to visit the premises with their families prior to moving in, to ensure it offers all the necessary facilities and can meet their personal needs appropriately. As part of the pre admission process, a senior member of staff also visits all potential residents and carries out a pre admission assessment. This outlines all the individuals’ care needs, wishes and preferences, and ensures that the home are confident they are appropriately equipped to meet these needs. We looked at the pre admission documents for two residents that had been admitted since the last inspection. These had both been carried out by the deputy manager at least two weeks prior to the admission, and contained sufficient detail of the individual’s present needs and history, to ensure that the staff had the skills and knowledge to fully meet them. Contracts and terms and conditions are in place for all the people who live in this home. This home does not provide an intermediate care service. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience good quality outcomes in this area. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been written in consultation with individuals and their representatives. Medication records were in order, contained the required entries and had been signed appropriately by staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Files were tidy and generally well organised. Care plans were well written, and contained sufficient detail to ensure that staff could deliver care with continuity. One of the files that we looked at Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 12 contained a document called. ‘Some of my Life’. This document was full of information relating to the individuals’ family, schooling, adolescence, significant life events such as her wedding, and the dress that had been made by an aunt. Retirement and life time hobbies, favourite foods and drink, and a gallery of old photographs. This document gave a clear illustration of this resident as an individual person with a past, and would help staff understand her and therefore have the background to deliver her care in a person centred way. There were numerous care plans in place for this resident, ranging from personal care to social activities and behaviour. They were written in detail so that staff knew the level of assistance required to meet this persons needs in a way that they prefer. For example, this particular resident could choose their own clothes, however these clothes had to be removed by staff for laundering each evening. One care plan also identified triggers, which may cause this person to become agitated and verbally aggressive. Therefore staff were aware of how to avoid these behavioural changes. Care plans were being generally reviewed on a monthly basis, however we also saw some that were being reviewed more frequently to address changing needs as they occurred. We discussed this with the manager who told us they are in the process of reviewing all these details, and we are confident that this process will be ongoing. Residents were relaxed, happy and well presented. Observations of care, identified people being treated with respect, and addressed in a way that was their preference The home is now addressing any deterioration of resident’s conditions through review meetings and consultants appointments in order to proactively identify, any areas of care, that this home may not be able to manage. During this inspection we examined the Medication Administration Record (MAR) sheets for all the residents who live here. These were tidy and well completed with signatures and omission codes where necessary. We chose six individuals’ medication stocks at random, to reconcile with the MAR sheets. All were correct. There were no Controlled Drugs (CD)s in use in the home at the time of this inspection, however appropriate storage and recording facilities are available if required. . Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. The service has a strong commitment to ensuring residents maintain personal relationships that are important to them. Suitable and meaningful activities are encouraged, and individual’s are assisted and supported to make personal choices. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection, one member of the care team has changed her role and now works part time coordinating activities. This has been a positive move for the home and has introduced activities such as a gardening club, which is presently running a sunflower growing competition. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 14 Other activities include, a film club, where the films have been chosen through resident’s questionnaires, and small group shopping trips, which are linked to the provisions for menus. During this inspection we observed a quiz session in progress. This home also integrates daily routines into meaningful activities for some residents, such as setting the tables or folding laundry. This home operates an open visiting policy, and relatives have the opportunity to join their loved ones for meals if they so wish. The food in this home is freshly cooked daily on the premises. There is a fourweek menu plan, which offers a wide variety of nutritious dishes. Menus are logged in a box file, and each ‘dish’ has a corresponding recipe number, so that if for any reason the chef is absent, staff have clear instructions for the preparation of each dish. The freezers are well stocked with small portions of alternative meals. On the day of the inspection, fish and chips were on the main menu, however there were a dozen alternatives available if preferred. These ranged from beef casserole to sweet and sour pork or Spanish chicken. The chef, who has completed her NVQ level 3 in kitchen management, speaks with each resident every day and keeps a record individual’s choices, she also monitors waste levels as an indication of which dishes are the resident’s favourites. Home baked cakes and desserts are cooked almost every day. Brook House DS0000014887.V374820.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience good quality outcomes in this area. The complaints procedure is supplied to everyone living in the home. Staff working at the home understand the procedures for safeguarding, and know when incidents need to be reported externally. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has a complaints policy, which is on display and easily accessible to residents and visitors to the home. This document details expected timescales for responses, and guidance for any complainant that remains dissatisfied with investigatory outcomes. We looked at the complaints file. There had been no written complaints since the last inspection, however the manager records every, verbal query or concern, and treats it as a complaint, keeping record of all responses. She is aware that for formal complaints, she must keep copies of meetings etc that form part of a formal investigation. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 16 The presence of numerous cards and letters of gratitude and thanks, indicates that residents and their families are generally very satisfied with the care in this home. One read. “Thank you for all the special care bestowed on our dad especially during the last three weeks of his life, above and beyond the call of duty”. Another read. “There are times when a simple thank you is totally inadequate, and that sums up how I feel. I really do wonder how I would have coped if it hadn’t been for you”. The manager demonstrated a clear understanding of Safeguarding protocols and related reporting processes. She has a basic knowledge of the Mental Capacity Act (MCA) and Deprivation of Liberty (DOLS) legislation and how it affects the residents in this home, and is aware of who she should contact if she requires further information. Both of these subjects are now included in the mandatory training for staff in this home. Brook House DS0000014887.V374820.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience good quality outcomes in this area. This home provides a clean, comfortable and homely environment for the people who live here. Individual rooms are furnished with personal possessions that reflect their personal life history. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home provides a clean, comfortable and safe environment for the people who live here. On the day of the inspection the home was warm and homely, with the small of home cooking throughout. The dining room was decorated to reflect a 90th birthday celebrations. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 18 Since the last inspection the manager has rearranged the communal areas to provide a more spacious dining area, and a smaller second lounge. All areas have sufficient space to accommodate the residents comfortably. The conservatory is now being used as an area for staff to have their breaks. Bedrooms were clean and tidy, decorated and furnished to personal taste, often reflecting the individuals’ life history. External decorating is in progress in this home and there are beautiful gardens to the rear, which are well tendered and provide a pleasant and private area for residents to relax weather permitting. Brook House DS0000014887.V374820.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. This service recognizes the importance of training and delivers a programme that exceeds the National Minimum Standards. Recruitment procedures are fully adhered to so that residents are protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home is presently fully staff and staffing levels are sufficient to meet the needs of the residents. In the morning there are three care staff plus ancillary staff. In the afternoon there are three care staff and at night two care staff. The manager and her deputy generally work between 09:00 and 17:00 hours, Monday to Friday, and provide an on call support 24/7. During this inspection we looked at the files of three staff that had been appointed since the previous inspection. Each file contained fully completed application forms, appropriate references, Criminal Record Bureau (CRB), POVA first checks, and Home Office documentation where necessary. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 20 Since the last inspection the manager has focused on the training needs of the home very thoroughly, and is now using a different training provider. Over recent months training has been provided in Moving and Handling, Safeguarding, Health and Safety, Mental Capacity Act and Deprivation of Liberty, Basic Medication training, Fire, Food Hygiene and experiential Workshops. The majority of staff have attended all of these subjects. In addition, two staff have completed an Advance Medication Course, four staff have attended a course of activities, and the manager and her deputy are undertaking computer literacy classes. An accredited Safeguarding course via long distance learning is in progress for many staff, 11 staff have completed NVQ 2 in care, and the kitchen assistant is doing her NVQ 2 in cookery. The deputy manager has completed her NVQ 3 in care, and the chef her NVQ 3 in kitchen management, the senior carer is also on course to complete her NVQ 3 in care. There is however a minority of staff who have not attended training as expected. The manager is aware of this and is taking steps to ensure this matter is resolved. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 People using the service experience good quality outcomes in this area. The manager has the required qualifications and experience to run this home. She is working continuously to make improvements to systems that may improve the lives of the people who live there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The past few months have been very difficult for this home, as the Responsible Individual (RI), who was very visible and involved in the home, sadly passed away. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 22 However the manager and her team have worked very hard to overcome this sad loss, and ensure that standards of care in the home were not affected in an adverse way. Consequently the standards have continued to improve, and the manager’s confidence has grown. The role of RI is in the process of being allocated to another of the home’s Directors, and regulation 26 visits are being carried out monthly by the manager of a neighbouring care home. This is proving very beneficial and the manager says it gives a clear vision of areas where further improvement can be made. This individual is also providing supervision, support and an appraisal process for the manager and her deputy. Since the last inspection there has been about eight staff changes, which the manager feels has been very positive, and has brought in new ideas. Supervision of staff is now divided between the manager, her deputy and the senior carer, and all the files that we looked at identified that the staff are receiving supervision at least once every two months, sometimes more frequently. Accidents and incidents are being appropriately reported via the regulation 37 notice process, and where necessary referrals are being sent to the Safeguarding team. This home ‘holds’ personal spending money, in a safe, for most of the people who live here. We looked at the accounts for six of these residents. Records were clear, with details of transactions and purchases and supporting receipts were present. We checked the funds remaining in each of these six accounts. All accurately balanced. Generally record keeping has improved tremendously in this home, changes in healthcare needs were being recognised and recorded proactively, however we did find one or two occasions where risk assessments were not always reflective of the care plans. The manager is addressing this at present. Health and safety checks including water temperatures, fire call bells, freezer and food temperatures are being recorded appropriately, and issues are addressed in a timely fashion. The manager has addressed quality assurance through resident and family questionnaires, and she has reviewed activities, in particular, as a result of these. She is presently awaiting responses from local health professionals that work with them. Audits have been introduced to monitor other systems such as MAR sheets and care plans. This is a very positive move and should continue. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 23 Throughout this inspection there were vast improvements noted, and we are confident these will continue. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 24 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 3 3 3 X 3 3 3 2 Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13(6) Requirement People who live in this home must be protected by risk assessments that are kept under review and reflected in their care plans. Timescale for action 31/05/09 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 OP38 Good Practice Recommendations The manager should consider an audit system for the risk assessment process. Brook House DS0000014887.V374820.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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