Inspection on 15/08/06 for 10 Brampton Court

This inspection was carried out on 15th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Brampton Court 30/06/08

10 Brampton Court 18/01/06

10 Brampton Court 14/09/05

10 Brampton Court 07/03/05

10 Brampton Court 08/06/04

10 Brampton Court 17/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Brampton Court (10) 10 Brampton Court Melksham Wiltshire SN12 6TH Lead Inspector Mrs Jacqui Burvill Key Unannounced Inspection 15th August 2006 10:15 Brampton Court (10) DS0000028375.V304840.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 Brampton Court (10) DS0000028375.V304840.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. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brampton Court (10) Address 10 Brampton Court Melksham Wiltshire SN12 6TH 01225 707233 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) Ordinary Life Project Association Mrs Teresa Trott Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: 10 Brampton Court is run by the Ordinary Life Project Association (OLPA). The home is a domestic style, detached property and located in a residential area on the outskirts of Melksham. There are some local facilities although one of the nearby towns is used for most shopping trips and services. The home has its own vehicle for trips out. The accommodation is on two floors. Each service user has their own room, one of which is on the ground floor. There is one communal room, which is used as a lounge and a dining area. Patio doors lead on to a garden at the rear of the home. There is a separate kitchen and a large ground floor bathroom, which includes a walk in shower. The service users receive support and personal care from a permanent staff team. Fees range from £756 per week. Inspection reports are available in the home. There is one service user vacancy. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on 15th August, when there was site visit to the home and two staff and three service users were met with. There was a site visit to the OLPA head office in Warminster in May 2006, when the records relating to recruitment were looked at. Following this visit, arrangements were made reflecting a change in guidance, so that a checklist of records could be held in the home, with original records being held in the office. Three relative surveys were sent out and completed. Due to the service users’ communication needs, two of them were unable to complete the CSCI survey for service users, as it was not in a suitable format. At the time of the inspection, the deputy manager was acting as manager for the home. There was a tour of the premises, and the following areas were looked at; care records, shared action plans, daily diaries, medication, health care records, menus, complaints and compliments, staff training, some policies and procedures, fire and health and safety records and quality assurance. What the service does well: Two relatives commented extensively by using the surveys, on how satisfied they were with the service they felt their relative received. They included; ‘couldn’t wish for a happier, safer environment …surrounded by loving care’. One went on to describe how they felt staff had been supportive to as service user during a recent time in hospital. The other relative commented on how they have never felt a need to complain. They also felt that their relative is especially well cared for when there is a health care need or appointment. Service users have comprehensive care plans and great care has been taken by the staff team to find ways of promoting choices to the service users, who have varying communication needs. This has been very successful and the acting manager was able to describe how this can promote further choices for service users in the future. This has been very successful in supporting service users in making choices over meals for example. Service users live a safe, comfortable and homely environment. Care is taken to ensure that aspects of the home, such as lounge and dining chairs meets individual service users’ needs. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 6 Fire safety records were in order and health and safety and risk assessment documents were in place and up to date. This shows that the health, safety and well being of service users is promoted and protected. What has improved since the last inspection? What they could do better: There has been one new requirement. This is because a controlled drug is now in use in the home. The acting manager was not aware of this and had not received guidance form the pharmacy. As a result, a count down of this medication is to be made every time it is administered. Four of the seven recommendations set have been carried forward from the last inspection. These were that a third party should be involved with agreeing terms and conditions of contracts; that licence agreements should include all those items specified under standard 5.2 of the National Minimum Standards; that work on the Shared Action Planning training is consistently and fully implemented and that the registered manager is involved in the formal interviews for new members of staff. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 7 Two new recommendations have been added; one is related to the complaints procedure. The organisation should ensure that there are systems in place to support service users who may need to use the complaints procedure, especially where they have communication difficulties. The other is that staff who attend fire drills should have their name recorded on the relevant form, which shows that the training they have received is effective when carrying out and attending a fire drill. 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. Brampton Court (10) DS0000028375.V304840.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 Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 This standard was not assessed as no new service users have been admitted since the last inspection. EVIDENCE: Information relating to the previous requirement regarding contracts was looked at and discussed. Service users who have lived in the home for some time still do not have contracts in place with the placing authority. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users may not be able to contribute to their care plan in a formal way, but their views, interests and known choices are included and regularly reviewed, as are any risks that may affect them. EVIDENCE: The care plan files for all three service users were looked at. Each contained a record sheet, which showed that they had been reviewed at regular intervals. This record also showed where any additions to the care plan had been made. Service users need full support from the staff team in managing all aspects of their lives and this has been carefully documented. Each service user has a description of their daily routine, on how service users are supported with managing personal care. The plan describes service users’ communication skills, with objective detail indicating that staff know service users very well. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 11 The daily diaries show objective descriptions of the lives of service users; this includes any choices they may have made, any behaviour they might have shown and activities undertaken, both inside and outside of the home. Each service user has a shared action plan, which is a way of service users being supported to choose their own goals and interests. This is a challenge in a home where service users have limited communication skills. Staff have been working with service users to promote choice. The staff team are identifying service users’ needs and wants, based on their knowledge and experience of them. Keyworkers are encouraged to sit with the manager and the rest of the staff team and discuss these goals. These goals have been broken down into smaller steps to ensure they can be achieved. There is a separate risk assessment file and this identifies risks that affect individual service users and those that affect the whole household. These are replicated in the care plan and there is a system for monitoring the risks. There was good supporting evidence with regard to a specific risk for a service user with evidence that it is reviewed periodically. The staff team have a rolling agenda for team meetings, which includes reviewing risks. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to take part in activities that they are interested in and have connections with. Service users are supported to make choices in a way that is meaningful to them, which is acted upon. This includes meeting friends, activities and meals as well as their rights and responsibilities in their everyday lives. EVIDENCE: There were statements in place describing how OLPA will supply staffing in line with an anti discriminatory policy. Preferences by people who are supported will be acknowledged within those parameters and when service users are unable to express these views, then efforts will be made to seek opinions from care managers, the family, or an advocate. This statement relates to service users who may need to receive personal care from a staff member of a Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 13 different gender. There was no evidence that further information had been sought. All of the service users have lived within the service for many years and staff believe that they are not concerned about staff of another gender that they know providing personal care. Each service user has a plan showing what activities they are taking part in outside of the home. There are concerns for the home, as these services appear to be reduced over recent months. Some of the changes have been having a disruptive effect on service users and staff have been working conscientiously to liaise with the day care service to minimise the distress service users may be experiencing. Service users have enjoyed a holiday at the OLPA caravan, where they were supported by staff. This has proved to be very successful, as a routine and familiarity is important to the service users who live in the home. Staff reported how each visit to the caravan has been more relaxed. Visitors are welcome to the home and family may visit at any time. There is another OLPA home close by and service users may meet other service users from there and meet other friends at their day care. There is further evidence in the care plan describing how service users have access to the phone or post, and the reasons why they may not have keys to the home. There is guidance that describes how service users are supported in managing their finances. Staff were able to show the inspector through care plans and discussions how they were supporting service users with choices, especially in choosing meals. Limited choices are offered, and this limited choice is carefully gathered from extensive knowledge about service users likes and dislikes, which is well recorded. Two service users choose meals at least once a week and one service user chooses the contents of their lunch box every day. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ health care needs are well supported and met, with good records showing what action has been taken. One aspect of medication storage and recording did not reflect best practice and guidance. Remaining practice and recording was well documented, protecting service users. EVIDENCE: Healthcare records are kept with medication records and show a very clear approach to recording the health needs of service users. There have been occasions when medical help has been sought and staff have ensured that service users are appropriately supported during these times. Service users have received screening tests for specific health care needs as well as more routine checks with the dentist, chiropodist and optician. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 15 Medication records were all in order with one exception. One service user is taking a medication that in care homes is classed as a controlled drug. The home was not aware of this and the pharmacy supplying this medication had not made the home aware either. The inspector asked the CSCI pharmacist inspector to write to the home advising them of the medication that may be classed as a controlled drug and how to store it and keep records. The acting manager was concerned that this information had not been available to him at the time the medication had been received and agreed to keep records as advised by the inspector. This medication needs to be counted and recorded each time it is administered and this record can be kept on the medication administration sheet, when staff sign the record. This is a requirement from this inspection. A check was made at the time to count this medication and it was all accountable for. There is a medication policy and procedure and staff have received medication administration training within the organisation before they are assessed as competent to administer medication. No service users are able to self medicate. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users views are respected and taken into account as much as possible, this would be further enhanced by systems that support service users to express their views. Service users are protected by adult protection systems in place, although one staff member during the inspection was not fully familiar with them. EVIDENCE: There have been no complaints received in the home or to the CSCI. The home has a complaints procedure and this contains the contact details for the CSCI. It is not clear what support service users may need in accessing this information if they needed to make a complaint. This is further compounded by their communication needs. Their views are listened to as far as possible, with a ‘tenant’ meeting held every month. Two staff support service users during this process and discuss the last month’s meeting and review the care needs and changes to health as well as reviewing the communication book for the day care centre. The staff try to gauge the views that may have been expressed by service users in response to situations or behaviours that may have been shown. A behavioural nurse is also providing support to the home to enable staff to further develop the way they support a service user with communication needs. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 17 There is an abuse policy and procedure as well as a separate file containing signposts that direct staff to the Wiltshire and Swindon adult protection procedure. Staff have signed to say they understand the policy and procedure. There are additional relevant policies and procedures in place, such as whistle blowing, bullying and harassment and managing service users’ finances safely. There was a discussion with one staff member about the adult protection procedure. This staff member could not recall exactly what the policy was called, or where it was. The acting manager was present and confirmed that staff had received this information. Service users’ financial records were looked at. Each service user has a checklist with receipts and notes on the balance, which is checked. There is a checklist for auditors to follow which assesses the ability of service users to manage their own finances. The records were checked and the balance was correct. One of the senior staff within OLPA acts as appointee for service users. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from a safe and comfortable home, which is clean and hygienic. EVIDENCE: At the time of the inspection, service users were sat in the lounge and each had their own individual chair. One of the chairs has a special adaptation to support the service users’ posture. The acting manager explained that another specially adapted chair was being sought for another service user. There is a dining area in the lounge and each service user has a special chair to support them sitting at the table. There are patio doors leading to a sheltered garden. A part of the garden now has a raised bed, which provides added depth and interest. Service users can sit outside in the garden, as there is plenty of seating and shade for the warmer days. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 19 Each service user has their own room, but they all prefer to spend time n the lounge together, rather than to sit in their own room. Each room is well decorated, clean and comfortable. There are three bedrooms for service users on the first floor as well as staff sleep in room. There is one vacant bedroom on the ground floor. There have been some improvements on the ground floor, as the old utility room has been changed into a walk in shower room with a toilet and hand washbasin. This has been decorated, tiled and finished to a high standard. The previous toilet has been turned into a utility room and storage room for medication. There is storage here for cleaning items, which has a safety catch. This change has made much better use of the space and anticipated the possible needs of service users in the future. Quotes are being obtained for re–carpeting the hallway, which will improve the entrance area of the home. The home was clean, tidy and smelled fresh on the day of the visit. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by a staff team who are aware of their needs and work together as a team to devise ways of meeting them. Over 50 of the staff are qualified at NVQ level 2 or above. Service users are supported and protected by the organsiation’s recruitment practice. EVIDENCE: The inspector spoke to one staff member who was on duty with the acting manager. At the time of the visit, the staff member was watching a fire safety video, in order to check answers to questions set as part of the training. Two staff are usually on duty during the day time, with one staff member sleeping in each night. One member of staff confirmed that she would be doing National Vocational Qualification at level 2, although she will not be doing Learning Disability Award Framework training, which leads to an NVQ. Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 21 Staff have completed first aid, health and safety, basic food hygiene, abuse awareness, mental health training, drug administration and fire safety training. Three of the five staff have NVQ level 2 or above. Two staff are to register in order to start NVQ level 2. There was a recommendation at the last inspection that staff attend training that informs them more about learning disability. Staff have attended an internal training course, which although entitled mental health awareness, did provide more detail and knowledge about service users who have a learning difficulty. Staff are also developing further knowledge from health care professionals, such as the behavioural nurse, from the community health team. Recruitment records were looked at during a site visit to the OLPA office in May 2006. These were all in order. As a result of a change in guidance, staff records can now be held in a central office, as long as a checklist is held in the home. These documents have been provided and an agreement has been reached between OLPA and the CSCI. Brampton Court (10) DS0000028375.V304840.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. There has been an arrangement to cover the registered manager during a period of absence. Service users have benefitted from a continuity of management during this time. Service users, relatives and outside agencies are contributing to a review of quality in the home. A clearer structure about the process would benefit service users. The health, safety and welfare of service users is promoted. EVIDENCE: There is an acting manager in post as the registered manager has been off sick since June 2006. The acting manager was the deputy manager in the home and has been able to provide some consistency in the management of the Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 23 home during this time. He has been supported by the service co-ordinator from within the organisation. A decision may need to reached in the near future about the registered manager’s post as a home cannot run without a registered manager indefinitely. The CSCI has been notified that the registered manager has been away from the home for 28 days and informed about the temporary arrangements to manage the home, which appear to be working well. The acting manager hopes to register to do NVQ level 4 in the future and gain the Registered Manager’s Award. The organisation have some quality assurance policies and procedures, which describe the following: the Annual General Meeting, service users’ questionnaires, tenants’ meetings, managers’ and team meetings, Regulation 26 visits, external inspections and the cross referencing of standards. The organisation has started to devise a system for gathering the views of service users, relatives and stakeholders. Managers have been asked to send questionnaires out so that information about these views on the quality of the service can be assessed. The form includes a section for comments and for people to think about one thing the organisation could do better. The quality assurance policy and procedure comments on the range of ways that quality had been assessed and this included Regulation 26 visits, which are unannounced visits by a representative of the registered provider and other methods. The policy and procedure needs to be amended to reflect this process. This should include the aims of the questionnaire and how the organisation plans to implement any changes that may be suggested. As previously stated at the time of the visit to the home, a staff member was taking part in fire safety training, by watching a video and checking answers to pre set questions. Fire safety records were seen and these were all in order. It was noted that staff are supporting service users to take part in a weekly fire drill, which the home decides to do in order to try and ensure service users are safe. Staff are not named when they attend a fire drill and this is a recommendation following this inspection. Staff training supports the conduct of staff during a fire drill and can highlight further areas of training required. Risk assessments have been devised following a recent small fire in one of the organisation’s other homes. Brampton Court (10) DS0000028375.V304840.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 N/A 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 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 25 Yes 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 YA20 Regulation 13 (2) Timescale for action Temazepam must be recorded as 30/09/06 a controlled drug. The medication administration sheet must show a count of the medication each time it is administered and signed by staff. The Commission is supplied with a report of the most recent review that has been carried out in accordance with Regulation 24 of the Care Homes Regulations 2001. COMMENT: The organisation has devised a questionnaire, which is being sent out to stakeholders, relatives and service users. Carried forward from the last inspection, due to be met by 31/03/06 31/10/06 Requirement 2. YA39 24 Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 26 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 YA5 Good Practice Recommendations A third party, usually the service users care manager, should be involved with agreeing any terms and conditions. COMMENT: Carried forward from the last inspection. That the licence agreements include all those items that are specified under Standard 5.2 of the National Minimum Standards. COMMENT: Carried forward from the last inspection. That work continues to ensure that the system of shared action planning is consistently and fully implemented. Refresher training for staff is recommended. COMMENT: This training is on going and is to be carried forward. The organisation’s complaint system should devise methods for how it intends to meet the needs of service users who may not be able to use the current complaint procedure due to their communication needs. That the registered manager is involved in the formal interviews for new members of staff. COMMENT: Carried forward from the last inspection. This has not been actioned as no new staff have been recruited since the last inspection. Staff should be named on the record when they have attended a fire drill. 2. YA5 3. YA11 4. YA22 5. YA37 6. YA42 Brampton Court (10) DS0000028375.V304840.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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