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Inspection on 19/10/07 for Brandley Residential Home (Sunflower House)

Also see our care home review for Brandley Residential Home (Sunflower House) for more information

This is the latest available inspection report for this service, carried out on 19th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff and the manager communicated positively with residents to meet individual needs and provide residents with a lifestyle suited to them. Good communications existed with the local Community Learning Disability Team and other health and social service officials to enhance the quality of care provided and to support staff members. Staff received training and supervision to enable them to fulfil their role. Records were well maintained and care plans and risk assessments were up to date. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. The residents who were interviewed and the results of both their CSCI survey questionnaires and the surveys returned from relatives and professionals communicated that a good service was provided and that residents are happy living in their home.

What has improved since the last inspection?

All requirements and recommendations made at the previous inspection had been implemented.

CARE HOME ADULTS 18-65 Brandley Residential Home (Sunflower House) Sunflower House 102 Durham Road Manor Park London E12 5AX Lead Inspector Keith izzard Unannounced Inspection 19th October 2007 10:00 Brandley Residential Home (Sunflower House) DS0000022856.V348070.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 Brandley Residential Home (Sunflower House) DS0000022856.V348070.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. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brandley Residential Home (Sunflower House) Address Sunflower House 102 Durham Road Manor Park London E12 5AX 020 8478 6233 020 8478 6367 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) Mr Andrew Garner Ms Beverley Beaupierre Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Can include one named service user with MH needs. To allow the home to provide continuous care for a named service user, who is now over the age of 65 years. 9th May 2006 Date of last inspection Brief Description of the Service: Sunflower house is run by Brandley Residential Homes. It is a four bedroomed property in a residential road in the borough of Newham. The home is registered for three adults between the ages of 18 and 65. However variations have been obtained for residents who are now over 65 years. Residents have learning disability and related mental health issues. The home aims to offer quality care services in a well-kept homely, non institutionalised establishment. The ground floor has a good sized kitchen diner, reception room, toilet and shower room and laundry room. The office is located downstairs. There is also a small courtyard garden and a small garden beyond the laundry room. There are currently three individuals living at Sunflower house and they are supported by a total of six staff including the manager. There is a sleep in member of staff. Residents have access to day services and are enabled to participate in community leisure activities. They are supported and encouraged to be as independent as possible. The range of fees for the present residents is between £640- £995 per week. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day over a period of six hours. All key standards were assessed including requirements made at the previous inspection.. The inspector spoke to two of the three residents and interviewed the manager and deputy manager and a care worker briefly. All care files and associated daily records were seen as well as staff personal files and records to do with health and safety matters. The Inspector toured the whole building. Overall, a good level of service was provided and residents appeared to be happy living in their home. The Inspector would like to take this opportunity to thank residents, staff and the manager at Sunflower House for their co-operation and assistance with the inspection. What the service does well: Staff and the manager communicated positively with residents to meet individual needs and provide residents with a lifestyle suited to them. Good communications existed with the local Community Learning Disability Team and other health and social service officials to enhance the quality of care provided and to support staff members. Staff received training and supervision to enable them to fulfil their role. Records were well maintained and care plans and risk assessments were up to date. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. The residents who were interviewed and the results of both their CSCI survey questionnaires and the surveys returned from relatives and professionals communicated that a good service was provided and that residents are happy living in their home. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Four requirements were made arising from this inspection. The related to the need to ensure that residents’ care plans are signed by the resident, or a relative/advocate and also the manager of the home. Two related to medication practice; to ensure the medication procedure includes comprehensive guidance and information about all aspects of medication. Secondly, that a formal means of assessing the competence of individual staff members be set up prior to them being allowed tom give allowed to give medication be set up. The results of the assessment must be recorded on the care worker’s training file. Lastly a requirement was made to strengthen recruitment practice by ensuring the verification of references provided for staff members. Seven recommendations were made: As a matter of good practice, placing authorities are persuaded to provide their own comprehensive assessments prior to the admission of a resident. The manager should consider obtaining medication training for staff members from an accredited external source and an up to date photo should be attached to each resident’s Medical Administration Record. More detail should be recorded to identify the cost to residents of their outings and personas expenditure. In respect of the building a lampshade should be attached to the landing light and blinds or curtains installed for the frosted bathroom window to improve the appearance of the room. Lastly, surveys of residents’ views on the service provided for them should be provided in a format that they would understand. Within a quality assurance programme, surveys should also be conducted of the views of relatives, involved professionals and all the results of surveys summarised and made available to all , including a copy to CSCI, annually. Please contact the provider for advice of actions taken in response to this Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 7 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. Brandley Residential Home (Sunflower House) DS0000022856.V348070.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 Brandley Residential Home (Sunflower House) DS0000022856.V348070.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager had the necessary skills and qualifications to assess residents prior to their admission to the home. EVIDENCE: Standard 2 The admission procedures in place, complied with Standard 2, evidence of this was seen during an examination of the records relating to the last service user, admitted to the home in May 2007. The records showed that there had been good preparation in terms of introduction to the home and a phased admission had been organised. In one resident questionnaire returned one resident wrote” before I moved to Sunflower House I had dinner there one night and the next week I stayed the night and liked it very much and I told my brother that I wanted to live there.” There was a comprehensive needs assessment on file, although it was noted that this had been substantially assessed by the manager of the home in the absence of full information being provided by care management in within the placing authority. It is recommended, as good practice, that placing authorities be persuaded to provide full assessment themselves prior to admission taking place. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 10 See Recommendation 1 Brandley Residential Home (Sunflower House) DS0000022856.V348070.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the Home are treated as individuals, and their care plans reflect their individual needs and wishes. EVIDENCE: Standard 6 All three care plans were seen and two were looked at in detail. It was noted that a previous requirement to provide one standardised, stand alone, care plan document containing all the information needed to deliver the care, and updated after any significant changes or at minimum once a year had been complied with. Individual plans were comprehensive and involved service users and their representatives, including family or advocates and other professionals Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 12 involved, however, those in attendance must be clearly listed. These plans are regularly reviewed but outcomes must be more clearly stated in response to the actions required at the previous review. Residents’ records included risk assessments and where risks were identified procedures and care plans reflected how these were being managed. None of the residents require personal care being given by staff except prompting to ensure tasks fully completed. Care plans must be signed both by a senior member of staff and the resident, their relative, or advocate. See Requirement 1 Standard 7 Any restrictions placed on residents are few and would be for the safety and welfare of service users, for example leaving the home unaccompanied. Evidence was available from the residents’ records examined that they are enabled to express choice in what they do and staff record these occasions. On a daily basis, staff do make attempts to involve service users in the running of the home this is evidenced in the daily diaries for residents but is limited to minor domestic tasks such as putting clothes away helping with cleaning and meal preparation depending on ability and this would always be under the direct supervision of staff members. Residents are able to express their preferred choice in relation to outings, meals and activities assisted by the historical knowledge of likes and dislikes built up by staff members about individuals and recorded in their care files. Staff members were reported to have developed good skills in facilitating communication with those who’s communication sometimes required some interpretation. Standard 9 Risk assessments were on file, and in individual cases had been updated to record where assessed risks may have reduced over time. Independence is promoted where possible. Any restrictions placed are minimal these are recorded in the care plan and would be for the safety and welfare of service users. Evidence was available from the service user’s records examined and from discussion with both service users interviewed that they are enabled to express choice in whatever they do. Brandley Residential Home (Sunflower House) DS0000022856.V348070.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): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are resident led and the approach to them from staff members is relaxed and empowering to the residents. Residents receive a varied and nutritional diet. EVIDENCE: Standard 12-13 Evidence was available from the care files examined that opportunities are being made available for the personal development of residents. Although owing to the level of learning disability and some associated communication difficulties none of the service users have been identified as being able to participate in employment full time. One resident currently attends a day centre places placement on a three day basis and one attends a work project four days per week the other resident, now retired attends college once a week All three residents have an activity plan that includes activities with a one to Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 14 one worker on the days when they do not attend day centres. The free days for resident can be an opportunity to spend more focussed time with a member of the care staff team, in particular their key worker and usually includes outings and shopping trips specific to that resident. Records showed that residents were supported to access leisure activities of their choice and to integrate with the community. A range of outings, for example, visits to pubs, cinemas, shops, sightseeing and annual holidays were all recorded. All residents have been increasingly involved in making decisions and personal choices regarding decoration and refurbishment of their home. The home has access to a people carrier that facilitates outings and other transportation needs. Standards 15-17 Two residents were supported to maintain positive relationships with their family and the manager for the other the manager has referred the resident to the local advocacy and befriending services and is awaiting a response. The manager reported that regrettably there are delays being experienced in the provision of advocates. One resident has very regular contact with her brother and this includes overnight stays at his family home. Also a sister in law and nephew visit a couple of times per week. Another resident has regular contact with her sister sand husband and regularly visits them at weekends. Residents are offered a healthy diet and enjoy their food and are able to express their individual choice in this area. One resident had been following a Chloresterol reducing diet but stopped it because of the success achieved, but now may need to reintroduce it. Menus for the home were examined covering a period of four weeks. Food stored within the home was seen to be plentiful, varied, and including fresh fruit and vegetables. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 15 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. Resident’s personal physical and emotional needs were being met and with the involvement of the resident, as far as this, could be achieved, as all residents have severe communication difficulties. Medicines were assessed as safely managed on the day of inspection but some areas of managing the system require improvements. EVIDENCE: Standard 18 Of the two residents interviewed one was clearly able to confirm that her needs were adequately met. All three residents had completed questionnaires, one with assistance form a key worker. All three were very positive in their comments regarding the support they received from staff members and the service provided for them. Care plans seen showed how care needs were to be met and staff spoken with displayed a good understanding of residents’ Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 16 personalities, needs and preferences in relation to how their personal care was provided. Two of the three residents were seen on the day of inspection and appeared well cared for and wearing age appropriate clothing. The individual daily diaries and communication book provided ongoing evidence of both the way in which personal care and support are provided to individual residents on a daily basis and that their physical and emotional care needs were being met. Standard 19 All residents were registered with a GP and staff supported them to access other medical services such as dental and optical care. Links were maintained with the community learning disability team to support staff with meeting service users’ needs. Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about resident’s individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. Evidence was available from care files and daily diaries in respect of service users that a wide range of health and related professionals are commissioned to attend to health needs on a regular basis, for example, Dentist, Psychiatrist, Psychologist Dietician and Dermatologist. It was noted that all three residents had been booked for dental check ups a few days after the inspection. Standard 20 The medication system was examined and medication was stored in a locked cabinet and quantities and dosage of medication tallied with the MAR sheets examined. Only two of the residents required medication and neither were assessed as capable of self-medication. The medication policy and procedure was reviewed and updated in 2006. The procedure did not include adequate information for staff. The procedure must be revised to include information about receipt of medication, record keeping arrangements, staff training, competency assessments, adverse reactions and covert administration. There was conflicting information about the storage of medicines in the procedure. See Requirement 2 Staff received ‘in house’ medication training. See Recommendation 2 There was no written evidence to show that staff members were assessed as competent to administer medication. See Requirement 3 Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 17 The home should put an up to date photo of the individual resident on their respective MAR sheet folder. See Recommendation 3 Brandley Residential Home (Sunflower House) DS0000022856.V348070.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): 22-23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were appropriately managed and to ensure protection for residents. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. The complaints, suggestions and representations procedure was examined. The procedure included information about the process, the timescales for responding to complaints and details of whom they could contact if they were not satisfied with the response. Information about the local CSCI office were out of date. The procedure acknowledged that there may be a conflict of interest if the director was asked to investigate complaints about his partner who managed the home. The procedure stated that complaints about the manager might be referred to social services for investigation. The procedure was rather complex in parts. A pictorial complaints leaflet was being developed to assist residents understand the facility and it was recommended that this be finalised as soon as possible. One complaint had been made to the provider, however this was subsequently withdrawn and is referred to in the next Standard 23. No complaints were made directly to the Commission since the last inspection. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 19 All three residents would have the ability to raise concerns, one spoken to by the Inspector indicated that she was happy within the home and had no complaints and all three resident questionnaires returned to CSCI indicated a high degree of satisfaction with the service provided by the home. One questionnaire indicated a lack of awareness as to how to make a complaint and this will hopefully be resolved when the pictorial complaints procedure is developed. See Recommendation 4 It was noted that the deputy manager had seen fit to make a complaint to a local hospital regarding the treatment one resident had received whilst attending a clinic. The deputy manager is commended for her appropriate advocacy as a letter of apology had been received and retained on the individual care file. Standard 23 The home had policies and procedures in relation to adult protection. One allegation of abuse had been made to the provider since the previous inspection and related to an allegation that home staff members had left a resident on the hospital ward without supervision or support. This allegation was later withdrawn by the Consultant who made it and a written apology was received by the home on behalf of the resident, following a complaint made by the deputy manager of the home to the hospital, referred to in Standard 22. The letter referred to was seen by the Inspector and it was noted that the correct procedures of reporting the incident to the local Safeguarding Adults team had been correctly implemented. The home had copies of the London Borough of Newham Safeguarding Adults Procedures and a whistle-blowing policy. The deputy manager interviewed by the Inspector indicated a good understanding of Safeguarding Adults procedures as evidenced by the example above. Since the last inspection some staff had attended training on adult protection. It was noted in the previous inspection report that the manager had been commended for producing a simple step-by-step adult protection procedure for staff to follow and staff members had signed to say that they had read and understood the procedure. The home had policies and procedures in relation to adult protection. The money records for two people were examined. The records seen were up to date and were signed by a member of staff and the person that lived in the home. All incoming and outgoing money was recorded and receipts were retained where possible. The cash kept in peoples cash tins corresponded with the balance recorded. Recent purchases included items such as personal clothing, “activities”, CD’s and a trip to the cinema. Staff should provide more specific information in the money records about “activities”. See Recommendation 5 All of the people living in the home had a personal bank account. Bank ledger books were stored safely and there was no evidence of any recent withdrawals. Brandley Residential Home (Sunflower House) DS0000022856.V348070.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable safe and hygienic environment. EVIDENCE: Standard 24 One resident showed the Inspector her room that was tidy, comfortable and personalised. The Inspector viewed the rest of the building accompanied by the deputy manager. The Inspector acknowledges that the property is old and must be difficult to maintain to a high standard. A number of shortfalls to do with the appearance of the building were identified in the previous report and were the subject of a recommendation the Inspector was pleased to note that these had been addressed. However, the landing light should be covered with a lampshade and it was suggested that the frosted window in the bathroom might be improved in appearance by the provision of colourful blinds or curtains. The deputy manager stated that an old chair in the front garden was scheduled for collection by the local Council refuse Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 21 service. Overall, the home was reasonably maintained and was homely, comfortable and safe. See Recommendation 6 Standard 30 A laundry is situated on the ground floor and is purpose designed and has a washing machine and incorporates a sluicing facility and a tumble dryer. Overall, the home was clean and hygienic on the day of inspection and appropriate infection control and COSH procedures were in place. Brandley Residential Home (Sunflower House) DS0000022856.V348070.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): 32,34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and cared for by competent and qualified staff members who act as a team to meet their needs. Recruitment practice was generally satisfactory. EVIDENCE: Standard 32 Training records for five staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for all new staff and foundation training following this. The home has already achieved the required minimum of 50 trained to NVQ Level 2, in fact, when one individual completes the training 100 will have been achieved, this is commendable. From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 23 skills and experience and that those staff observed had the requisite attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions or engagement in activities. Standard 34 Five personnel files were examined for in respect of recruitment practice and found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. However, one reference received had not been provided with a company stamp or compliment slip. In these circumstances the reference must be verified by the manager by contacting the referee to ensure the reference is genuine and this be recorded on the personal file. See Requirement 4 Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for new staff and foundation training following this. Overall, a comprehensive spread of training had been provided for staff members and included annual updates in fire training and moving and handling. Brandley Residential Home (Sunflower House) DS0000022856.V348070.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 &42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Surveys of relatives and professionals views on the running of the home must be publicly available and residents’ surveys made more user friendly. The health and welfare of service users are promoted and protected EVIDENCE: Standard 37 The Registered Manager is experienced and has the necessary NVQ4 qualification. Two staff members interviewed stated that she is approachable Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 25 and supportive and would not hesitate to discuss any concerns about the home or the welfare of service users with her. Communication within the home was of a good standard with team meetings held regularly and the manager, overall, complies with the requirements of Standard 37. The manager had undertaken training in order to update her own skills and knowledge. Standard 39 There were systems in place for monitoring the quality of care provided in the home and for obtaining feedback about the service. This included health and safety audits, spot checks, unannounced visits, house meetings and satisfaction surveys. Some of these checks and audits were completed regularly but others such as the spot checks and health and safety audits had not been completed for some time. Surveys of residents’ views on the service provided for them had been conducted although these were positive they do require amendment to be more user friendly for those with learning and communication difficulties. The home should also survey the views of relatives and involved professionals annually and produce a published summary of the combined results that is available to all. See Recommendation 7 Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. As an Environmental Health inspection had not been conducted in the past the manager agreed to request one, however, no concerns were identified during the inspection in respect of the kitchen or laundry areas. COSHH procedures were in place and hazardous items locked away in the kitchen area, thus complying with a previous requirement. A number of areas were picked at random and checked against the pre inspection questionnaire (AQAA), in respect of routine health and safety checks such as fire drills and other areas requiring maintenance checks. This information provided, was accurately recorded and in accordance with that submitted by the manager to the CSCI. For example, Fire Extinguishers were checked on 06/05/07, PAT testing completed on 25/07/07, gas inspection conducted on 11/05/07 and electrical circuits tested 05/2006 and therefore current within a five yearly testing regime. Fire drills had been held regularly within quarterly periods at different times of the day and had included night time care staff and therefore complied with a previous requirement. A record of weekly testing of call points was also maintained. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 26 One accident since the previous inspection had been recorded well with outcomes noted and appropriate action taken including follow up by staff members. Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 27 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 2 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 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 (1) Requirement The Registered Person must ensure that unless impractical, the care plan is signed by the manager and resident or relative/advocate. The Registered Person must ensure that the medication procedure provide guidance and information for staff about all aspects of medication management. The Registered Person must establish a formal means to assess whether the care worker is sufficiently competent in medication administration before being allowed to give medicines. This process must be recorded in the care worker’s training file. The Registered Person must ensure that staff references are verified with a company stamp /compliment slip or further verified by the manager and this recorded. Timescale for action 01/02/08 2 YA20 13 01/02/08 3 YA20 13 01/03/08 4. YA34 19 01/03/08 Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 29 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 YA2 Good Practice Recommendations It is recommended, as good practice, that placing authorities be persuaded to provide full assessment themselves prior to admission taking place. The Registered Person should consider obtaining medication training from an external source. An up to date photo should be attached to each residents MAR sheet folder. The Registered Person should provide a copy of the complaints procedure, in a suitable format for each of the people living in the home. The contact details for the local CSCI office should be updated. The Registered Person should ensure that adequate detail is recorded about the use of personal money. The landing light should be covered with a lampshade and it was suggested that the frosted window in the bathroom might be improved in appearance by the provision of colourful blinds or curtains. The Registered Person should ensure that satisfaction surveys are provided in a format that people living in the home will understand. A quality assurance programme should be developed. The home should also survey the views of relatives and involved professionals annually and produce a published summary of the combined results that is available to all. 2 3 4 YA20 YA20 YA22 5 6 YA23 YA24 7 YA39 Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 Brandley Residential Home (Sunflower House) DS0000022856.V348070.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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