Care Home: Brooklands

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What the care home does well Information is available about the service, and what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Brooklands provides opportunities and support for people to maintain their interests and any hobbies they may have. Brooklands looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Brooklands. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Brooklands makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Brooklands.People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. Advocate support is encouraged where people do not have any relatives. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are provided, and snacks and drinks are available at all times. What has improved since the last inspection? A new care plan format has been developed which gives more detailed information to help staff support people who use the service. Parts of the home have been redecorated and include some of the bedrooms. People have chosen their colour schemes for their rooms. The front and back gardens have been laid with paving slabs. The ensuite bathroom and downstairs shower room have been replaced and redecorated. The front of the house has been repainted. A handrail has been fitted to the front of the building so that it is easier for people to get in and out of the front door. CARE HOME ADULTS 18-65 Brooklands 92 Northwick Road Evesham Worcestershire WR11 3AL Lead Inspector Dianne Thompson Unannounced Inspection 25 April, 7 May and 23rd May 2008 10:30 th th Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brooklands Address 92 Northwick Road Evesham Worcestershire WR11 3AL 01386 40207 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) Yunicorn Limited Carol Mary Thomas Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2006 Brief Description of the Service: Brooklands is an end of terrace property that occupies a corner position in a residential area of Evesham. The premises are within a short walking distance of the town centre where there are shops, restaurants, GPs surgeries and all of the other social amenities associated with a small town. Brooklands is registered to provide residential care for people with a learning disability. People who use the service are accommodated on the ground and first floor in five single and two double bedrooms. The second floor provides a selfcontained flat, which is occupied by a member of staff. Access to the first and second floors is gained via a central staircase. The home does not have a lift. The laundry is situated in a separate building in the rear garden. Details of fees for the service are included in the Service User Guide. Brooklands DS0000018638.V363409.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 was an unannounced inspection visit to see what the home was like for the people who live there. Time was spent talking to some of the people who live at Brooklands and some of the staff working there. We looked at some of the policies and procedures in the office with the senior staff on duty. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Brooklands and the plans that are in place to make the service better. A tour of the premises was also done. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI, has been included in this report. What the service does well: Information is available about the service, and what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Brooklands provides opportunities and support for people to maintain their interests and any hobbies they may have. Brooklands looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Brooklands. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Brooklands makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Brooklands. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 6 People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. Advocate support is encouraged where people do not have any relatives. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are provided, and snacks and drinks are available at all times. 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. The summary of this inspection report can be made available in other formats on request. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Brooklands has policies and procedures in place for assessing potential people to live at the home. Information about the service is included in a Statement of Purpose and Service User guide and these are available for all enquirers and residents. There is currently a vacancy at Brooklands. The admissions procedure states that people are given a copy of the statement of purpose and service users’ guide on admission. The admissions procedure states that full community care assessments are required and that Brooklands would complete their own assessments. Care plans are written from the information gathered during assessments, visits, and discussions with families and other interested parties. The manager states in the AQAA that ‘all outside agents and family are also involved in this Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 9 process. A contract is agreed between the resident, families, advocates, professionals and the home. A copy of the contract is drawn up in a format suitable for the individual.’ Surveys confirmed that information about the service is shared and people are kept up to date with important issues. People who use the service confirmed they have a copy of the statement of purpose and service user guide that includes a copy of their contract. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. EVIDENCE: Care plans for three people were viewed and all contained information about their needs and how they were to be met. The service has developed a new care plan format since the last inspection and this includes information about daily living needs, health and personal care, physical well-being, social Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 11 interests and relationships, religious and cultural needs and any other specific areas for each person. Evidence shows that care plans are regularly reviewed. This was confirmed with people who use the service. One person said they were ‘ having a meeting to talk about things in my plan next week’. The manager states in the AQAA that ‘personal files, care plans, daily record sheets and minutes of any meetings’ are maintained. ‘Accurate records are kept of all residents finances and they also have full access to this information at anytime’. Staff said they are fully aware of the plans and follow them to guide their practice. People are allocated a key worker to oversee their care. This allows staff to work on a one-to-one basis and contribute to the care planning process for each person. Risk assessments are completed to keep people safe and these are supported with suitable guidelines for staff to give assistance as necessary. Completed risk assessments show dates for planned reviews and explore ways to make sure that people are able to be as independent as possible. Some of the risk assessments had not been reviewed as specified. This was discussed with the manager, who said that reviews are to be completed. The manager was advised to be realistic about timescales of review for each risk assessment, making sure that an appropriate date was specified. Where people who use the service have no relatives the support of external advocates are encouraged. This is an example of good practice that makes sure that peoples’ best interests are maintained. Survey responses confirm that people are ‘happy with the home’ and the service Brooklands provides. People confirmed that they are given information and kept up to date about any changes within the service. People who use the service said they ‘can choose what they want to do’ and are able to make decisions about their lives in the home. One person spoke about their future plans and how these are being supported by the service. Another person said ‘I like it here, I like the people, I don’t want to move’. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to take an active part in their choice of activities. Everyone is supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Brooklands are encouraged and supported to make choices about activities and daily living. People make choices about how to spend their day and examples of this were observed throughout the inspection visits. Various recreational activities are offered. The manager says in the AQAA that ‘a planned schedule of activities is to be prepared in advance, further promotion of independence for example residents gaining employment’. The service has an activities co-ordinator who plans activities with people who use the service one month in advance. The daily record sheets confirm the activity Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 13 schedule is working. People attend many groups and have lots of opportunities to go into town socialising and going to the pub with friends. Three people no longer receive day activities due to changes with the local authority services and alternative activities have been sought by Brooklands. Some people attend day centres in Evesham, the music club, the advocacy project group ‘prospect’, and life links. People talked about their morning at the church ‘open house’ session during the inspection visit. Another person went into town to do some food shopping with staff support. People In Action (PIA) are providing support for 4 hours per week for one person where day services are no longer available. There is no record of the activities completed by PIA and the manager was advised that this information should be obtained. Two people regularly attend St James Bungalow for sessions on meal preparation and cooking skills. Evidence was seen in care plans to show daily routines and support given for specific interests. One person now has a job working at the local hospital and was happy to talk about this. It was evident that this is enjoyed and the individual says he is ‘very proud’ to be employed. People who live at Brooklands confirmed that they are encouraged to share in all aspects of housework within the home with staff support. Holidays are regularly planned and last year two holidays were taken to the Isle of Wight. People went on holiday to Blackpool in March and another holiday is being arranged for October. Evidence shows that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirmed that they are made welcome. Advocates provide support where people have no relatives. Records show that varied and nutritional meals are provided. Details of food eaten are recorded in care plans. People are offered meals, with snacks and drinks available throughout the day. People are consulted about their choice of food and diets. Staff confirmed that choices and alternatives are offered. Lunch on the day of the inspection visit consisted of sausages, potatoes, carrots and gravy. People who use the service said ‘ the food is nice here, ‘there is a good choice and we can choose the menu’. Another person said she sometimes helps out in the kitchen and was seen to be doing so during the inspection visit. Surveys confirm that the service ‘supports people to live the life they choose’ and that staff are helpful and supportive, although one person says that they feel ‘staff sometimes don’t listen’. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Brooklands. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Brooklands has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Care plans include detailed information about each persons health needs. These plans set out how health needs are to be met and records show that regular checks and monitoring are being carried out. The manager states in the AQAA that ‘personal and healthcare needs are identified in the care plans for each resident. Each resident has their own health action plan book, this covers all aspects of health from dentistry to psychologists.’ Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 15 Evidence shows how information is used to make any changes to each persons support if it is needed. People have good access to medical services through their Primary Health Care team as required. This includes psychologist, physiotherapists, chiropodist, dentists and GP. A record of visits to the doctors or other medical professionals is maintained in individual health action plans. Information about exercises advised by physiotherapist is included in care plans and a completed chart shows that these routines are being followed. Some charts had not been updated and weight charts not completed. This was discussed with the manager who said that work is being done on all care plans to make sure that all aspects are up to date. Staff were observed providing support for people in a respectful way, making sure that dignity and self esteem was important. People who use the service confirmed that staff ‘help us if we need it’ and that regular meetings take place to make sure their personal and health care needs are being met. A policy and procedure is in place for the administration of medication. All the staff who are involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems which may occur. The manager says in the AQAA that ‘an audit is carried out by a pharmacist from Boots to ensure the correct procedures are being followed’. The administration of medication was observed and all procedures were followed. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. Policies and procedures are in place to make sure that people who use the service are protected from abuse. EVIDENCE: Brooklands has a complaints policy and procedure in place which is accessible to people who use the service and their relatives. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the AQAA that no complaints have been made to the service. The CSCI has not received any complaints about Brooklands. One person said they ‘don’t understand the complaints procedure but if they had any worries they would talk to the manager’. Regular meetings are held for the people who use the service to share any concerns they may have. Minutes of these meetings are available. Procedures are in place that guide responses to any allegations of abuse and in managing any complaints made about the service provided. There are specific policies and procedures are in place for the protection of vulnerable adults from abuse and ‘whistle blowing’ for staff. Staff receive training in abuse Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 17 awareness, and the staff on duty confirmed this. Staff also confirmed the procedures they would follow should they suspect abuse or have any concerns. The manager confirmed in the AQAA that ’policies and procedures are currently in place that help protect all people concerned with Brooklands from abuse, neglect and self-harm. There is also available within the home a copy of the No Secrets document. The homes whistle blowing policy has been fully updated. There is also within the home guidance for staff on how to report and follow procedures if a case of abuse occurs, for example the Adult Protection Team’. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Brooklands enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A tour of the home was conducted by some of the people who live at Brooklands. People talked about how they had chosen colour schemes and furniture for their bedrooms. Brooklands is located in a residential area of Evesham. The service provides residential care for adults with learning disabilities. Some people have additional physical disabilities. There is a lounge, separate dining room, kitchen, conservatory, and downstairs shower room with a toilet. There is a small front garden and a larger garden with raised beds to the rear of the property. People who use the service are accommodated on the ground and first floor in five single and two double bedrooms. The ground floor bedroom has en suite facilities. The second floor provides a self-contained flat, which is Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 19 occupied by a member of staff. Access to the first and second floors is by a central staircase. The home does not have a lift. The laundry is situated in a separate building in the rear garden. Local shops and access to public transport are situated nearby. Brooklands has its own vehicle for people to use locally. The property is accessible, comfortable and provides a homely environment for the people who live there. The home is clean and tidy throughout and there has been redecoration and improvement since the previous inspection. The kitchen has been completely refurbished; the front and back gardens have been paved. The en suite bathroom and the downstairs shower room have been completely refurbished. All the guttering at Brooklands has been replaced. The front of the house has been repainted. A handrail has been fitted to the front of the house to make it easier for people to get in and out of the front door. Three bedrooms have been repainted to the colours and choices of people who use the service. People who live at Brooklands confirmed this. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Staff were observed wearing suitable protective clothing for the work they were doing, and confirmed that they are familiar with the procedures regarding the control of infection. The manager says in the AQAA that ‘three members of staff have attended and completed cross contamination and infection control training’. Records show that staff have received training in health and safety matters. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are enough staff on duty with the right skills and knowledge to meet the needs of people who live at Brooklands. Staff are well supported and work together to provide consistent and quality care. Staff receive relevant training to help them meet the needs of people who use the service. A recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to keep people living at Brooklands safe. EVIDENCE: Brooklands has a committed and stable staff team, and is now fully staffed following a successful recruitment campaign. Staff spoken to confirmed that the team work hard to improve the lives of the people who use the service. People commented in surveys that they were generally satisfied with the service and the staff. Brooklands operates a recruitment policy and procedure to ensure that everyone completes an appropriate application form and that suitable Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 21 references are obtained including one from their most recent employer. Appropriate criminal records and other checks are made before appointments are confirmed. The manager confirms in the AQAA that ‘all the necessary checks are carried out before any new member of staff starts working for Brooklands’. All staff are required to work a probationary period. Newly employed staff confirmed the recruitment policy and procedures had been followed. An induction checklist was seen which shows that staff cover required areas during their induction programme. The induction training programme records were made available for inspection. Training records show details of all training provided and planned. Staff complete mandatory training such as Safe Handling of Medicines, Infection Control, Epilepsy, Dementia Awareness and Health and Safety. Staff appeared to be enthusiastic and well motivated. They said they are well supported and are given the opportunity to share their views and opinions at staff meetings. Staff confirmed that they have regular team meetings and minutes of these meetings are kept. The manager aims to develop the structure of supervision for care staff to include all aspects of care practice, philosophy of care in the home and career development needs. Staff confirmed that regular supervision takes place. New members of staff said that its ‘really good here, always doing something’ and that the ‘staff are nice. They have made me feel welcome’. Surveys confirmed that staff are always helpful and supportive. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. The service is well managed and staff receive the leadership and support they need. Yunicorn monitors Brooklands in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Ms Carol Thomas has many years experience working with people with learning disabilities. Carol has recently achieved her Registered Managers’ Award (RMA) and is working to complete her NVQ level 4. Carol regularly completes training relevant to her position as registered manager of Brooklands, including medication and vulnerable adults training. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 23 Management responsibilities in the home are shared with three senior support workers. They are involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. Staff confirmed that the manager is approachable and supportive. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI when requested. The AQAA is where the manager tells us about the service provided at Brooklands and the plans in place to make the service better. The provider’s monthly visits are one of the ways that Yunicorn Ltd monitors the service and how it is being run. These visits include interviews with staff and people who use the service. The manager receives supervision every two months from the provider. A regular audit takes place and includes records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of Brooklands quality assurance and monitoring system that should form an annual development plan for the service. The quality assurance process seeks the views of people who use the service, stakeholders and interested parties about the service that is provided. The manager was advised that a report of the findings of the audit and questionnaires should be compiled and an action plan for the coming year developed. This process should be completed annually and include a review of the previous action plan. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. This meets the requirement of the previous inspection. Staff are undertaking all mandatory health and safety training topics. Evidence has been provided to show that the new conservatory complies with the building control regulations. This meets the requirement of the previous inspection. Risk assessments are carried out and recorded for safe working practices. Records confirm that all equipment and safety checks are completed regularly. The manager states in the AQAA that ‘the home also has in place COSHH policy, risk assessments, visitors signing in book. Fire alarms are regularly checked and also call buttons within all rooms are checked’. A recent audit by the Environmental Health Officer resulted in Brooklands being awarded a 3 star good rating. Brooklands DS0000018638.V363409.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Brooklands DS0000018638.V363409.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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard YA9 YA39 Good Practice Recommendations Risk assessments should be reviewed by the dates specified. A report and action plan should be completed from the review of the service. Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brooklands DS0000018638.V363409.R01.S.doc Version 5.2 Page 27 - 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. 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