Inspection on 11/09/07 for Brabyns House

This inspection was carried out on 11th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Brabyns House 13/10/06

Brabyns House 16/01/06

Brabyns House 18/04/05

Brabyns House 01/11/04

Brabyns House 08/06/04

Brabyns House 11/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Brabyns House 98 Station Road Marple Stockport Cheshire SK6 6PA Lead Inspector Steve Chick Unannounced Inspection 11th September 2007 10:45 X10015.doc Version 1.40 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 Brabyns House DS0000008542.V344035.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 Older People. 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. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brabyns House Address 98 Station Road Marple Stockport Cheshire SK6 6PA 0161-427 4886 0161 427 4886 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 John Arthur Odell Mrs. Kathryn Joan Odell Mrs Lynette Anne Stainton Care Home 39 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (39) of places Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 39 OP and up to 5 DE (E) Date of last inspection 13th October 2006 Brief Description of the Service: Brabyns House is a large, detached property situated adjacent to Marple locks and canal. Local shops, parks, public Houses and restaurants are all close by, enabling service users to independently, and with support from family and staff, visit places of interest. The home is owned by Mr Odell, who takes an active interest in the home and visits each week to undertake an assessment of the building and to consult with the manager. The home is well maintained in both the communal and private parts of the building used by service users. Service users have the use of four lounges during the daytime and evening. There are two dining rooms, one of which overlooks the rear gardens and is enjoyed by service users at all times of the day and evening when, after meals, it is used by service users who play cards and dominoes. Twenty-one of the 31 single bedrooms have en-suite facilities. The home offers four double bedrooms to those service users who prefer to share. The fees for accommodation range from £385 to £560, depending on the accommodation available. Service provision is the same and not dependant on fee structure. Individual fee structures should be discussed and agreed before a decision about accommodation is finally made. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included an unannounced site visit to the home. All key standards were assessed. For the purpose of this inspection four service users were interviewed in private as were three members of staff. Additionally discussions took place with the manager and a representative of the owner. The inspector also undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. This report also uses information gathered since the previous visit, including 11 respondents from a questionnaire sent to service users and 6 from a questionnaire sent to relatives. The manager had completed an Annual Quality Assurance Assessment (AQAA) which is a self assessment process and which was available before the visit took place. Most, but not all, of the information received both before and during this unannounced visit was positive in connection with the standard of care provided to service users by the staff at Brabyns House. Service users comments included absolutely first class I really do [ like it] and up to my expectations … the atmosphere is very calm. Staff are attentive. … I realise that I am very fortunate to be living in such a caring residential home and hope to remain here for the foreseeable future. Comments from relatives when asked what Brabyns House does well varied between takes great care of my mother, she is always clean and tidy, she has always got a smile when I visit which tells me she is happy with care and surroundings. Has caring and friendly staff … all mums needs are catered for to, not a lot. What the service does well: Brabyns House offers care in a pleasant, homely and well maintained physical environment. There is good contact with the full range of medical practitioners in the community help to ensure that service users health is maintained. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 6 The staff team maintain the dignity of service users, who have a high degree of autonomy and choice in the way in which they lead their lives on a daily basis. The home provides good quality food in ample quantities and respond to individual’s likes and dislikes. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. Service users are only admitted to the home after an appropriate assessment, to ensure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA completed by the manager stated that before a potential resident is admitted a pre-assessment form is completed. A selection of files relating to service users was looked at. All had a copy of an assessment. Not all assessments seen were signed or dated. The absence of a date on the assessment made it difficult to confirm that this had been undertaken prior to the person moving to the home. All service users who completed and returned Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 9 a questionnaire stated that they received enough information about the home before they moved in to decide if it was the right place for them. Brabyns House does not offer intermediate care. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Service users have individual plans of care, which are regularly reviewed to ensure they reflect current needs. They have access to appropriate community based medical services to ensure their health needs are met. Staff practices serve to promote the dignity of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During this visit a selection of service users’ files was looked at. All had a copy of a written care plan. There was also documentary evidence that the care plans were periodically reviewed. The detail of the written plans varied significantly. It was clear that these variations reflected the dependency of the service user, so service users with more significant needs had more detailed written plans. Brabyns House uses a structured set of pro forma to record the Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 11 assessment of needs, the long-term and short-term plans for meeting those needs and a record of care actually given. Although these are comprehensive, there was some evidence that they were not always fully completed, with the result that care needs were not always recorded as having been met. Similarly, although there is the facility on the format for service users to sign to confirm that they are in agreement with the care plan, no service user signatures were on the care plans which were looked at. An example of a risk assessment relating to the use of bed rails was looked at. The documentation did not provide sufficient evidence that all the potential risks had been assessed. Discussion with the manager indicated that this was an administrative issue and that in reality potential risks were assessed. Service users who returned questionnaires mainly confirmed that they did receive the care and support they needed, although two respondents replied sometimes in response to that question. Similarly one respondent to the relatives questionnaire indicated that their relatives needs were met sometimes. All service users who were interviewed during this visit were positive about the way in which their care needs were met. One service user observed that people were dealt with, with incredible patience. Another said the staff cant do any more for you. Staff who were interviewed reported that a combination of the documentation, their personal knowledge of service users and the verbal handovers which take place at each change of shift, ensured that they were always aware of major issues affecting individual service users. There was documentary evidence that service users have access to the medical and paramedical services which are available in the community. At the time of this unannounced visit an optician called to repair the spectacles of one service user. All service users who were spoken to expressed confidence that the home would summon medical support in a timely manner. In the responses to the service user questionnaire eight service users reported that they always receive the medical support they needed, two reported usually and one sometimes. One service user commented that they had noted positive relationships between the staff and district nurses. The home has a written procedure in connection with the control, storage, disposal, recording and administration of medicines. The AQAA provided by the manager indicated this was reviewed in July 2007, and was not looked at on this inspection. Medication was seen to be stored appropriately. A separate fridge was provided for the storage of medication which needed to be kept refrigerated and records of the fridge temperature were maintained. There was Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 12 documentary evidence of medication administration records being audited by a senior member of staff, which is good practice. It was reported by the manager, that service users are able to administer their own medication subject to a risk assessment. One risk assessment was looked at and was in insufficient detail. Potential dangers had been identified but no written explanation was available which demonstrated how these dangers would be minimised. Observation and discussion with service users and staff indicated that the service users were treated with respect and their dignity was maintained. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Appropriate social contacts and activities are facilitated within the home to give service users the opportunity for social fulfilment. Service users are able to maximise their autonomy within the context of communal living. The provision of food to maintain service users’ health and well-being is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence relating to the availability of social activities was inconsistent. Service users who were spoken to were generally positive about the range of activities available, although one felt there were less entertainments than in the past. This service user acknowledged that their feeling may be a reflection of the poor summer weather restricting their ability to enjoy the gardens. Five respondents to the service users questionnaire, when asked are there Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 14 activities arranged by the home that you can take part in? replied sometimes, four usually, one never and none always. Service users do benefit from dedicated activities coordinators who visit two to three times a week. A record is maintained of who participates in which activities at these sessions. One service user confirmed that structured activities take place every Friday morning (for those who wish to participate) and also described staff putting on films, lots of board games -- dominoes etc - all of which were available for anyone to use at any time. Brabyns House also benefits from the home library service. The home has a policy of allowing visitors as any reasonable time. One service user said she felt visitors were made to feel welcome and are offered a drink etc. One service user appreciated the fact that the grounds were kept nice and there was always seating and cubbyholes where you can take friends. One service user confirmed that they had holy Communion at the home on a regular basis and stated that Brabyns House was situated in a particularly caring parish. Service users spoken to confirmed that staff at Brabyns House encouraged a high level of autonomy and choice. One service user commented that the home was not regimented, there is basic organisation but the organisation is for the people not the people for the organisation. Service users are free to spend time in their room, or use any of the communal facilities. One service user who chooses to spend much time in their room confirmed that assistance came quickly when needed. Another service user said they liked the fact that there were a lot of lounges and they were free to go wherever they wanted, and the fact that televisions are not on all the time. The manager reported that there was a completely ‘ open door’ policy with respect to service users. She was aware that this would impact on the safety of any service user who was likely to be unaware of their surroundings, particularly as the home is situated on a busy main road. The manager reported that this was a criterion which she considered when assessing potential service users and reassessing the changing needs of existing service users. One service user identified as one of the best things about Brabyns House, the freedom to go out and that it is close to the centre of town. All respondents to the relatives questionnaire responded either always (4) or usually (2) to the question does the care service support people to live the life they choose?. All service users spoken to were positive about the provision of food at Brabyns House. One meal was sampled during the visit which was both tasty and pleasantly presented. One service user confirmed that the daily menu was always written up and that you could ask for an alternative. This service user described a nice atmosphere in the dining room and said a cry goes up if there is no serviette . Another service user said they were happy with the food and liked the fact that they could ask for smaller portions or second Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 15 helpings. Service users confirmed that they had been encouraged to state preferences. Respondents to the service user questionnaire, when asked do you like the meals, 6 replied yes, 3 replied usually, and 2 replied sometimes. Comments in the questionnaires included - vegetables not cooked sufficiently -- excellent, not only is the cooking good, meals are attractively served and staff pay attention to particular likes and dislikes … -- very good wellprepared fresh food One relative reported in a questionnaire that the food and choice of food is excellent. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users are confident that any complaints they may have would be dealt with appropriately and are protected from abuse or exploitation by the homes policies and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Brabyns House has a written complaints procedure which has been found to be appropriate on previous inspections and was not looked at on this visit. All respondents to the service users questionnaire said that they knew how to make a complaint, as did five of the six respondents to the relatives questionnaire. All service users who were asked, expressed confidence that they could make a complaint. They were also confident that they would be listened to and that both staff and management would be appropriately responsive. All staff who were interviewed were confident that both they and their colleagues would respond appropriately to any complaint. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 17 The AQAA reported that the home kept a record of all written complaints. The complaints log was looked at and presented as being an appropriate record of written complaints. Keeping a record of less formal complaints may assist the management to monitor if any patterns of minor concerns are developing so that appropriate action can be instigated. CSCI had received a complaint since the previous visit which was forwarded to Brabyns House for a response. Whilst the response to this complaint presented as being appropriate, it was not addressed within the required time scale. It was reported in the AQAA and by the manager that all staff had received training with regards to the protection of vulnerable adults. Staff who were spoken to expressed the view that service users were safe, that they understood the need to be vigilant about potential abuse and they understood their responsibilities to whistle blow if necessary. All service users who were spoken to reported feeling safe at the home. When asked they also expressed the view that other service users in the home were also safe. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 16. Quality in this outcome area is good. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit to the home of a tour of the building was undertaken. This included communal areas and a selection of service users bedrooms. There were several communal areas where service users could spend their time, or they could access their rooms when they chose. One service user spoken to confirmed that they chose to stay in their room most of the time whilst another appreciated the fact that there were a range of lounges he could visit. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 19 At the time of this visit the weather was very pleasant and several service users were observed sitting in the well maintained gardens. Service users expressed satisfaction with the accommodation, with one saying they had a lovely room and another saying they were very happy with their room. Discussion with the manager, service users and observation confirmed that people were able to personalise their room. No remedial issues were identified in connection with the fabric of the building or the furnishings. Issues identified by one relative in their questionnaire which was returned, relating to poor heating in a bedroom was reported by the manager to have been resolved. A maintenance book was seen which clearly indicated that staff were encouraged to record any routine maintenance requirements which were then addressed by the handyman. At the time of this visit the home presented as clean and tidy with no offensive odours. This was confirmed as the usual state of the building by service users and staff who were talked to. When asked if the home was clean and fresh all respondents to the service user questionnaire reported either always (9) or usually (2). One respondent expressed the view that sometimes staff shortages affected the standards of cleanliness. However all service users who were spoken to during the inspection reported positively on this aspect of life in the home. One said cleanliness is fantastic, another said that the staff are very good at keeping the place clean and there was never a smell and a third included as one of the best things about the home, that it was so clean. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. The numbers and skill mix of staff on duty generally promote the independence and well-being of service users. Recruitment and vetting procedures are not effectively applied to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota for the week beginning 03/09/07 was looked at. This demonstrated that there were usually five members of staff on duty during the day, sometimes six and occasionally four. At night three carers were on duty. The manager reported that one of them was able to sleep during the early hours of the morning if their services were not needed for the benefit of service users. The staff Rota also highlighted which first aider was on duty. It was reported in the AQAA and by the manager at the site visit that 22 of the 31 carers held NVQ II. Two of the three care staff who were interviewed confirmed that they held NVQ II qualifications. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 21 A selection of staff files was looked at in connection with recruitment and vetting procedures. It was reported that very few new staff had been appointed (who were still working at the home) since the previous inspection visit. Some gaps in the vetting procedure were identified, including the absence of a full employment history and no written explanation in connection with a reference which could have been interpreted as poor. The manager reported that this information was known but accepted a record needed to be maintained. It should be noted that issues which had been identified at the previous inspection in connection with recruitment had been satisfactorily addressed. Due to the reported difficulty in recruiting staff, agency staff were sometimes used. There was documentary evidence provided to the home, by the agency to confirm that these staff had been appropriately vetted. Although the level of staff holding NVQ II was good, discussion with the manager and staff, together with the information provided in the AQAA indicated that there were some areas, particularly in connection with health and safety training, which required updating. The home had itself identified the need for updated training in first aid, moving and handling and food hygiene. The manager reported difficulty in obtaining places on these courses for the staff. Respondents to the service users’ questionnaire were generally positive about the staff team. All but one reported that staff listen and act on what they say. However, comments included some carers dont have time to listen to my needs … whilst another respondent said as every resident is different staff are faced with getting to know their individual realities, which they soon do remarkably well. Service users spoken to during this visit were very positive about the staff team. When asked what the best thing about Brabyns House was, one identified the kindness and understanding of staff, and another that staff are so kind. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The manager is appropriately experienced and qualified to run a care home for the benefit of service users. Quality audit processes provide a framework to further improve services to service users whose financial interests are protected by the homes procedures and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 23 The manager has many years of experience of both care and management. Since the last inspection she has successfully completed the RMA and documentary evidence of this was seen. There was, theoretically, a clear management structure within the home which included designated senior staff on duty even if the manager was not present. However, not all staff were confident that all suggestions always reached the manager. Similarly some comments from respondents to questionnaires indicated a lack of clarity or understanding of the management structure at Brabyns House. Comments included … but sometimes there is no management cover on a Sunday, occasionally … no real leadership/Management. Staff and service users spoken to, described the manager as approachable and supportive. There was documentary evidence of quality assurance questionnaires are being sent out by the home, to service users and relatives, in August 2007. Whilst many of these had been returned, at the time of this visit the outcomes from these questionnaires had not been analysed or acted upon. A quick look through these questionnaires indicated a predominantly positive response to the questions asked. The absence of analysis and an action plan was identified in the homes AQAA as an area for improvement. A sample of records relating to money held and spent on behalf of service users was looked at. The record is presented as being appropriately maintained. The manager reported that a representative of the owner audits these records on a monthly basis. Previous inspections have usually found appropriate systems in place to ensure necessary health and safety regimes are maintained. A small sample of current documentation was looked at, which presented as being appropriately maintained. Staff reported the availability and use of personal protective equipment such as disposable gloves and aprons, to minimise the risk of cross infection. As mentioned elsewhere in this report some basic and mandatory health and safety training for staff needed to be updated. No mobile hoist was available at the home. This is unusual in a care home dealing with older people who may have limited mobility or who may be at risk of falling. Staff who were spoken to believed that a hoist could be useful. This was discussed with the manager who did not believe that a hoist would be advantageous given the dependency of the service users, but was confident that the home owner would purchase one if it was thought to be necessary. Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement Timescale for action 01/10/07 2 OP38 13 The registered person must ensure that the vetting of staff is undertaken with reference to the most up to date legislation, to minimise the chances of employing staff who may pose an unacceptable risk to service users. In particular this relates to obtaining a full employment history and the nature of references which should be sought. The registered person must 01/12/07 ensure that staff receive appropriate training in connection with health and safety issues to minimise the risk of injury to either service users or staff. In particular this relates to moving and handling methods. Brabyns House DS0000008542.V344035.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 OP7 Good Practice Recommendations The registered person should ensure that service users (or their representative if appropriate ) sign to confirm they have been involved in and are in agreement with the written care plan. The registered person should ensure that documentation held on service users’ files actually reflects the care which has been provided for the individual. The registered person should ensure that individual risk assessments help to manage identified risks for service users. The registered person should ensure that all ‘complaints’ are recorded, even if not received in a written format and even if quickly resolved. This would aid transparency and enable the early identification of any slippage in the home’s good standards. The registered person should ensure that managerial lines of accountability are clarified both with staff and relatives, or representatives, of the service users. This is to ensure good communication to the benefit of service users. The registered person should undertake thorough risk assessments to demonstrate that service users remain safe without the provision of any mobile hoists. These risk assessments should be regularly reviewed. 2 3 4 OP7 OP7 OP16 5 OP31 6 OP38 Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Brabyns House DS0000008542.V344035.R01.S.doc Version 5.2 Page 28 - 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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