Care Home: Brookside

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What the care home does well Person Centred Plans (PCP) provided detailed information, to ensure that staff were equipped with the knowledge about the level of support and assistance people required to live a lifestyle of their choice and promote their independence. Efforts had been made to publish the homes policies and procedures in a format that promote people`s understanding, for example, the Statement of Purpose, Service User Guide and the Complaints Policy. The home was in the process of the Changing Lives Programme. (This is where Social Services review the current provisions provided to people, in view of the imminent closure of the home). Every effort had been made to ensure that people were fully aware of the impact this would have on their life. What has improved since the last inspection? Requirements identified within the last inspection report had been addressed. For instance, sufficient catering hours were now provided to ensure that people`s nutritional needs are met appropriately. Records confirmed that water temperatures were regulated to ensure peoples safety and fire doors were working properly. The home does not have a Registered Manager but an Acting Unit Manager had been appointed. This should ensure the home is being properly managed. What the care home could do better: The service AQAA showed that there were some short fallings with the number of staff provided, to meet people`s needs. Staff told us that incidents that required the attention of more than one staff member did result with other people being left unattended.The registered person must ensure that appropriate measures are taken to guarantee sufficient staffing levels are provided at all times to meet people`s assessed needs. CARE HOME ADULTS 18-65 Brookside Giggetty Lane Wombourne Wolverhampton WV5 0AX Lead Inspector Dawn Dillion Key Unannounced Inspection 19th June 2008 09:30 Brookside DS0000033607.V366825.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 Brookside DS0000033607.V366825.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. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brookside Address Giggetty Lane Wombourne Wolverhampton WV5 0AX 01902 894485 01902 893167 julie.lindsayayres@staffordshire.gov.uk 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) Staffordshire County Council, Social Care and Health Directorate Care Home 16 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (2), Learning disability (16), Mental disorder, of places excluding learning disability or dementia (1), Physical disability (5) Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager is to complete the NVQ Level 4 by the end of 2005 14th July 2006 Date of last inspection Brief Description of the Service: Brookside is a residential home owned by the Local Authority and is located in Wombourne, Staffordshire. The home provides a service for adults of both genders who have a learning disability. The two-storey property is divided into units and efforts have been made to provide an ethos of normal daily living within each unit. Each unit provides a lounge area, kitchen and bathroom, equipped with furnishings to meet the needs of people who use the service. All bedrooms are of single occupancy and are tastefully decorated to reflect the individuals interests, there are no en suite facilities however; bathrooms and toilets are located in close proximity to both bedrooms and communal areas. Specialised equipments such as a hoist, nurse call alarm system and handrails are provided through parts of the home. Bedrooms are located on both the ground and first floor; there are no passenger lifts in place. People have access to relevant healthcare services if and when required. Staffing is provided on a 24-hour basis to ensure the support and supervision of people. Information relating to the fees charged for the service provided at the home was not made available; the reader may wish to contact the home directly for this information. Brookside DS0000033607.V366825.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 Star. This means the people who use this service experience good quality outcomes. The unannounced key inspection of Brookside was conducted within eight hours. The emphasis of the inspection is to look at the quality of outcomes with regards to people’s lifestyle and practices that promote equality and diversity. The inspection methods used to establish the quality of care provided and the effectiveness of the management of the home involved the examination of records, relating to the home’s policies and procedures. During the inspection we talked to one person who used the service and three staff members, to gather an overview of the quality of service provided. People who lived at Brookside have complex care needs and were not able to express their views but we observed interactions between them and staff. Information from the service Annual Quality Assurance Assessment (AQAA) is also incorporated in this report. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. A tour of the property was undertaken, to ensure that the environment and systems in use were safe and suitable to meet people’s needs. The Acting Unit Manager was present during the process of the inspection. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service AQAA showed that there were some short fallings with the number of staff provided, to meet people’s needs. Staff told us that incidents that required the attention of more than one staff member did result with other people being left unattended. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 7 The registered person must ensure that appropriate measures are taken to guarantee sufficient staffing levels are provided at all times to meet people’s assessed needs. 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. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 8 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 Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 9 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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given relevant information to enable them to establish if the home will meet their assessed needs to promote their wellbeing. People can be confident that their assessed needs will be met to promote their welfare. EVIDENCE: We looked at the home’s Statement of Purpose, which showed that people were given relevant information, to enable them to establish if the home would be suitable to meet their needs. For example it told us about the experience and qualification of the Acting Unit Manager, staffing arrangements, how to make a complaint, facilities available in the home, amongst other things. Staff told us that the Statement of Purpose could be made available in various formats such as Braille, cassette, video, compact disc (CD), digital video disc (DVD) and different languages on request, to promote people’s understanding. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 10 We also observed that people had a copy of a Service User Guide that provided them with additional information about the home. We saw that information about the fees charged for the service was not included in the Service User Guide. The Registered Person should ensure that people are provided with this information. Staff told us that one person had been admitted to the home since our last inspection visit. Records showed that the home did a Needs Assessment. This assessment enables the home to gather what people’s care needs are and the level of support they will need to promote their health and welfare. The service AQAA stated, “All service users are assessed prior to admission to ensure that the home is able to meet their needs and we hold regular meetings to ensure that Person Centred Plans remain appropriate and continue to meet the individual needs.” Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to make decisions about their lifestyle, participate in their care planning and are assisted to take a risk to live an independent life. EVIDENCE: The Needs Assessment provided the basis for the development of the Person Centred Plan (PCP). The PCP provided staff with guidance about the support and assistance the individual needs to live an independent lifestyle. For example assistance required when eating and drinking, ensuring that people receive their prescribed medicines and the daily support required, to ensure their safety and welfare when engaging in daily life activities. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 12 We looked at three PCP’s, which showed that people were able to participate in planning their care. For example we observed that some people had signed their PCP, they were also reviewed and updated on a regular basis to reflect the changes in people’s needs. The service AQAA stated, “We support our service users to contribute to their Person Centred Plans and to attend regular review meetings regarding their Person Centred Plans wherever possible.” We observed that the PCP included a 24 hour support plan that provided brief information about the support people required when retiring to bed, their dietary needs and daily pastimes. The service AQAA stated, “Person Centred Plans reflect everything that we do to support our service users.” “They contain information about the day to day lives of our service user, the level of support required, routines and risk assessments.” We observed information displayed in the home and in the PCP’s that people had access to a self-advocacy service. This service provided independent support. The PCP provided information on how to support people to make decisions. For example, making sure people are aware of the choices made available to them and encouraging people to make decisions. We saw that PCP’s included a risk assessment, which provided information about potential hazards and gave the person and staff guidance on how to reduce or eliminate the risk. This enabled people to take an informed risk promoting their independence and rights. The service AQAA stated, “We recognise that risks are a part of everyday day life, and we support our service users to take risks.” Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 13 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 and 17 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 various social activities but the absence of sufficient numbers of staff means planned activities are limited and may not always promote choice and individuality. EVIDENCE: Discussions with the Acting Unit Manager and information contained within the service AQAA showed that the home was currently going through the ‘Changing Lives Programme.’ This is where Social Services review the current provisions provided to people, in view of the imminent closure of the home. Information contained within the PCP’s showed that people were being kept informed about any changes to the service. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 14 People also had access to a self-advocacy service. This is an independent service that provided people with support. The home was registered to accommodate sixteen people; staff told us that fifteen people were currently living in the home. Thirteen people attended day care services throughout the week. Staff said that the day centre provided an educational base to enable people to learn new skills. Staff told us that people who attend day care services were able to access the local college via this route. Meridian House, a detached property located near the home would be used for training in promoting independence. One person who lived at the home said, “I go to the day centre four days a week and on Thursday I go shopping and do the housework.” Two people who chose to remain in the home during the week had a structured activity programme, consisting of horse riding, swimming, music, dance, home based activities and community visits out for lunch amongst other activities. Staff told us that no one was in paid employment and in some cases this was due to lack of mental capacity but said employment had not been considered. We spoke to staff and PCP’s we looked at showed that people had access to local amenities and leisure services. Social activities consisted of shopping trips, walks, cinema, bowling and day trips. The service AQAA stated, “Social activities during the evenings and weekends also take place where staffing permits.” The home was divided into four units with four staff on duty during the day. Staff told us that insufficient staffing levels had a negative impact on the choice and frequency of social activities provided. The service AQAA showed that the home was looking at increasing staffing levels in the evenings and weekends to increase the range of opportunities for social activities and to encouraged people to take more responsibility such as domestic tasks, preparing meals and doing the laundry. The service AQAA also confirmed, “Staffing is an issue.” “As we only have thirteen day staff we are sometimes limited in what we can do in terms of social outings, particularly at weekends, due to low staffing levels.” People were provided with the necessary support to enable them to maintain contact with their family and friends. Staff told us that the home provided transport for one elderly relative to visit the home on a regular basis, to ensure they were able to maintain contact with their daughter. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 15 The service AQAA stated, “Key workers/link workers support service users to maintain contact with family and/or friends.” “Staffing is provided to facilitate home visits when required, and families/friends are always welcome within the unit.” The home had a four-week menu that showed an alternative choice, staff told us that they were in the process of seeking advice from a Dietician to promote healthy eating. No one required a special diet due to culture or religion. We looked at a PCP that showed the assistance the person required when eating and drinking, for example one person needed their food cutting up because they had swallowing problems. People were able to make light meals and snacks in their flat. One person told us; “I make my own sandwiches in the flat.” Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that the health and personal care they receive is based on their individual needs and ensures their wellbeing. A thorough medication system ensures that people receive their medicines to promote their health. EVIDENCE: We saw that detailed PCP’s were in place and provide relevant information about the level of support and assistance people required to maintain their personal and healthcare needs. One PCP we looked at included a Communication and Activity Passport; this gave staff some guidance on how to communicate with the person. Written protocols were also in place to assist staff in managing challenging behaviours. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 17 PCP’s showed that one person had access to the Community Learning Disability Team (CLDT) for anger management. The service AQAA identified, “Action plans formulated with service user involvement wherever possible, give specific detail about their preferences relating to personal care.” PCP’s showed that people had access to healthcare services, to promote their physical and mental health, for instance a Consultant Psychiatrist, General Practitioner, Optician and Dentist. We observed that the home’s medication system and practices were thorough and ensured that people received their medicines as directed by the doctor. The home used homely remedies, we saw a written protocol that was signed by the doctor authorising the use of these medicines. We looked at medication administration records that were signed to show that medicines had been administered. The Acting Unit Manager told us that staff who were responsible for administering medicines had attended the Safe Handling and Administration of Medicines training. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to an effective complaints procedure. Robust staff recruitment procedures ensure people are safeguarded. EVIDENCE: The home’s complaint procedure was displayed in the main entrance of the home and was accessible. The complaints procedure was published in pictorial format, to ensure that people understand the contents. One person told us that if they were unhappy they would tell the Acting Unit Manager or a member of staff. She said, “The staff do listen to me.” There was a safeguarding policy in place; this is a document that tells staff what to do to safeguard people from abuse. The policy did not provide contact details of relevant agencies to be contacted in the event or suspicion of abuse. This information should be added to the policy to assist staff. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 19 We were introduced to the new Unit Manager who told us that training relating to the protection of vulnerable adults would be delivered to staff members on 22 June 2008. One out of three staff we spoke to told us they were aware of the Whistle Blowing Policy. This is a policy that ensures that staff feel able to report any incidents of possible abuse or concerns without fear of reprisal. Staff told us they had not received any complaints since the last inspection visit. There had been two safeguarding referrals relating to the same incident, this allegation was investigated by Social Services and the Police and was not substantiated. We have not received any complaints or further allegations about the home since the last inspection. Staff told us that some people displayed challenging behaviours. One PCP included a written protocol used by staff to assist them with the management of behaviours. PCP’s showed that physical intervention was used. This is where it is deemed necessary to use a form of restraint to prevent the person harming themselves or others. There was also a written ‘Emergency Physical Restraint’ procedure in place. Discussions with the Acting Unit Manager and staff members confirmed that physical intervention was only used by staff who had received the appropriate training. We looked at three staff personnel files that showed appropriate safety checks were carried out to ensure that people who use the service were protected from possible abuse. People who used the service needed some support with their financial affairs and this was identified in their PCP. We looked at three records and funds all were well managed. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people to live in a safe, well-maintained and comfortable environment to ensure their welfare. EVIDENCE: Brookside is located in Wombourne, Staffordshire; the home is situated within the grounds of a Special School and is not visual from the road. The home was accessible via public transport and was in close proximity to local amenities. The two-storey property was divided into four units providing accommodation for sixteen people on both the ground and first floor. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 21 All bedrooms were decorated to reflect the individual’s interests and chosen design. The service AQAA stated, “All bedrooms are individually decorated to reflect the likes/dislikes of the service user.” Bedrooms were not equipped with en suite; washbasins were fitted in all bedrooms. Bathrooms and toilets were located near to bedrooms and communal areas. Information contained within the service AQAA and discussions with staff confirmed that the home didn’t have a shower facility due to traces of Legionella in the water supply. This was being monitored; people did have access to other bathing facilities. The home offered a lounge and a separate dining area on the ground floor, equipped with essential furnishings and fitments. Brookside also offered two self-contained flats, which were located on the ground and first floor. Staff told us that equipment and adaptations needed to promote people’s independence were available. For example, an assisted bath, hoist and ramp access to the property. Our observations confirmed the equipment was in place and used for the benefit of the people who use the service. There service does not have a passenger lift. The service AQAA stated, “Although Brookside is earmarked for closure under the Changing Lives Programme we aim to continue to keep the Unit as well maintained as possible to ensure that service users have a homely, comfortable environment in which to live.” The home was clean, tidy and appropriate systems were in place to promote infection control, such as a washing machine equipped with a sluice programme. Staff members had access to disposal gloves and aprons. Two out of three staff that we spoke to told us they had undertaken infection control training. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 22 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, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are trained and skilled but insufficient numbers of staff may have a negative impact on the level of supervision provided to people and necessary to ensure their welfare. EVIDENCE: The service AQAA told us that fourteen out of twenty four people employed within the home had obtained a National Vocational Qualification level 2 in care or above and one person was working towards the award. One person told us, “I like the staff they are nice.” As previously stated in the report, Brookside was divided into four units. Four staff members were provided during the day to meet the needs of fifteen Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 23 people some of which, displayed challenging behaviours and sometimes required assistance from more than one staff to protect them or others from harm. Staff told us that incidents requiring the attention of more than one staff member often resulted in other people being left unattended. One staff member said, “Sometimes we are OK, sometimes we are not, if an incident happens, you feel vulnerable due to the staff shortages.” Another staff remarked, “We try not to let it have an impact on the service, we pull together.” The service AQAA identified a vacant 37 hour Support Worker post but due to the Changing Lives Programme, they were unable to fill the vacancy. The service AQAA also stated, “Staffing is an issue.” “As we only have thirteen day staff we are sometimes limited in what we can do in terms of social outings, particularly at weekends, due to low staffing levels.” “In the event of an aggressive outburst staffing may be increased using agency staff if necessary in the short term.” “A safe staffing levels risk assessment is in place.” Information supplied by staff and in the service AQAA indicated that the staffing levels were sometimes inadequate to ensure the supervision and protection of people at all times. We looked at three files pertaining to staff employed within the home, all showed that appropriate safety checks were undertaken prior to people commencing employment. This ensured peoples’ protection. For example each file contained evidence of a Criminal Record Bureau clearance and two satisfactory references. Staff told us that the Local Authority had stopped staff training within the last twelve months but training was again being offered to staff. Discussions with staff confirmed that they had received the following training: Fire Safety, Infection Control, Health and Safety and Physical Intervention. The home was able to offer a service for people with a diagnosis of dementia but at the time of the inspection, but at the time of the inspection, the home did not have anyone assessed as requiring these specialist services. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 24 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 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect to promote the welfare of people. An effective quality assurance system promotes quality standards to guarantee people’s rights and independence. EVIDENCE: The home did not have a Registered Manager; the Acting Unit Manager told us that she was leaving her post on 21 June 2008. A new Unit Manager had been Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 25 appointed and was due to commence employment on 22 June 2008. The new Unit Manager was an internal candidate and has experience of the provision of social care. Information obtained from the Statement of Purpose showed that the Acting Unit Manager was suitably qualified and experienced in social care. For instance she had an Honours Degree and was currently undertaking a Masters Degree and had obtained the National Vocational Qualification in Care. One staff told us, “The management support is fine and the transition between managers has been fine, they are both good.” Further comments received from staff about the management of the home were as follows: “We have got a new manager starting, at the moment we are fine, management wise we are happy.” “The management support is brilliant.” The service AQAA showed systems were in place to promote quality standards. For example regular self-advocacy meetings ensured that people were actively involved in the management of the home and were aware of any forthcoming changes. The service AQAA provided open and transparent information about the positive aspects of the service and contingency plans to address areas of weakness. We looked at a number of records that showed that safety checks were undertaken on a regular basis to ensure the safety of people. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 26 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 3 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 2 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 3 X LIFESTYLES Standard No Score 11 X 12 2 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 3 X X 3 X Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 27 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 YA33 Regulation 18(1)(a) Requirement A review of the staffing arrangements must take place and action taken to ensure sufficient numbers of experienced and qualified staff are available. This is so that the people who use the service can be confident their needs will be met and their health and safety promoted and maintained. Timescale for action 30/10/08 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. 1. 2. Refer to Standard YA1 YA23 YA23 Good Practice Recommendations The Service User Guide should provide information about the fees charged for the service and provisions. To ensure that the safeguarding policy provides contact details of relevant agencies. To ensure that all staff are given a copy of the home’s Whistle Blowing policy. Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 28 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 Brookside DS0000033607.V366825.R01.S.doc Version 5.2 Page 29 - 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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