Inspection on 01/08/06 for Bracken Lodge

This inspection was carried out on 1st August 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bracken Lodge 03/09/07

Bracken Lodge 07/10/05

Bracken Lodge 18/05/05

Bracken Lodge 20/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bracken Lodge Bracken Lodge 155/157 Foxon Lane Caterham Surrey CR3 5SH Lead Inspector Joseph Croft Unannounced Inspection 1st August 2006 09:30 Bracken Lodge DS0000013572.V306086.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 Bracken Lodge DS0000013572.V306086.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. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bracken Lodge Address Bracken Lodge 155/157 Foxon Lane Caterham Surrey CR3 5SH 01883 348961 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) A N J Coowar Limited Katja Pauline Crutchley Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: Bracken Lodge is situated in a quiet residential area of Caterham, a short distance from the local shops and amenities. Care and accommodation is provided for up to ten younger adults with learning disabilities. The bedroom accommodation is provided on the ground floor and first floor levels, and consists of one shared and eight single bedrooms. Bathroom and toilet facilities are provided on both floors. There is a communal lounge and a smaller quiet lounge on the ground floor for the residents to use. The home has a large conservatory, which is used as a dining room and activities area. The property is two semi-detached houses that have been joined together. There is a large garden to the rear of the property. Car parking facilities are available to the front of the home. The fees range from £800 to £ 1000 per week. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the manager, staff, and residents who were at the home at the time of the inspection. There are currently ten residents living at the home, two of whom are recent admissions. During discussions residents stated they were happy living in the home, that the food was good and they liked the activities offered. Residents’ bedrooms had their personal belongings such as televisions, pictures, and family photographs. Residents stated that they like the staff, and they help them to make choices regarding their daily lives. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support residents. Feedback was provided at the end of the inspection to the manager. The inspector would like to thank the staff and residents for their cooperation during the inspection. What the service does well: Prospective residents are provided with appropriate information about the home. The home has regard for ensuring written needs assessments are undertaken prior to admission to the home. The home has clear care plans and risk assessments in place that ensure the needs of the residents are met. Staff in the home encourage and enable residents to participate in a range of activities both within the home and the local community. The home offers a healthy balanced diet. Physical and emotional health care is offered in such a Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 6 way as to promote residents independence. The residents are protected by the home’s storage, administering and recording medication policies and procedures. The home has a satisfactory complaints system to enable residents and their families to raise concerns. The home provides adequate communal and individual living space making it a safe and comfortable place to live. The arrangements for management and administration ensure the home is run in the best interests of residents, and the safety of residents is promoted and safeguarded. What has improved since the last inspection? What they could do better: The Protection of Adults Policy and Procedure must be reviewed to ensure it is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults. The manager must locate the employment history of one identified member of staff, or the member of staff concerned must provide another full employment history. Gaps in employment must be recorded. The registered person must ensure that all staff have an individual training and development assessment profile. The registered person must develop a system to ascertain the views of residents’ representatives in regard to the quality of care they receive. The manager must locate the fire risk assessments or make the necessary arrangements to reproduce them. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 7 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. Bracken Lodge DS0000013572.V306086.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 Bracken Lodge DS0000013572.V306086.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with appropriate information about the home and have their needs assessed to ensure they can make an informed choice about where to live. EVIDENCE: The home has produced a comprehensive Statement of Purpose and Service Users Guide, which provides clear information of what the home offers, the care philosophy, aims and objectives, statement of rights, services offered, how to make a complaint, daily routines and organised activities. The manager stated the home is to invest in computer software that will enable the Service Users Guide to be written using symbols and pictures to ensure all current and prospective residents can easily understand the contents. The manager and staff stated residents had been provided with a copy of the Service Users Guide, but they kept returning their copies to the office. The home has an admissions procedure that is followed when referrals to the home are made. This provides clear step-by-step guidelines on the process for admitting new residents to the home, clearly stating the criteria and process for admission. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 10 Prospective residents are invited to visit the home and offered an overnight stay prior to moving in. The manager stated that a place would not be offered to a resident whose needs could not be met. The home has recently admitted two new residents. The pre-admission assessments from their care managers were viewed, and contained the appropriate information required. Staff at the home had written individual care plans from the pre-admission assessments. The inspector talked to the two new residents, however, only one was able to fully communicate. This person described, in the best way they could, the admission process they went through. They stated that on their first visit to the home they knew they wanted to move in. Bracken Lodge DS0000013572.V306086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear care plans and risk assessments in place that ensure the needs of the residents are met. EVIDENCE: All residents have individual care plans. Three care plans sampled evidenced how the assessed needs are to be met, which included Mental health, physical needs, audio, eyes, communication, dental, sleep, allergies, medication, personal and health care, lifestyle, leisure activities and religious and spiritual needs. Evidence was viewed that care plans are reviewed every six months. Each resident’s file sampled evidenced statutory annual reviews had been undertaken. Due to the low levels of understanding, residents spoken to did not understand the concept of ‘care plans’, but were aware they have a certain member of staff who they can talk to, and who supports them when required. Residents Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 12 discussed the activities they like to attend, which reflected the recordings in their care plans. During discussions, staff were able to give an account of the content of care plans for the residents with whom they key work, and were aware of the need to review care plans every six months, and when required. The manager stated the home is to commence using Person Centred Plans (PCP), and is waiting for a trainer to return from sick leave to discuss this further. Residents stated that they make choices about themselves, the activities they like to do and the food they would like to eat. One resident stated that he chose the colour for his bedroom, which was viewed by the inspector. Staff stated that residents are involved in making decisions about their lives; records of decisions made by residents are maintained in the daily records kept by the home. Evidence was viewed of individual risk assessments in the care plans, and included risks on falling, use of hairdryers, kitchen, windows, bedroom, garden and falls. All risk assessments sampled provided evidence that they were last reviewed on the 28th July 2006. Bracken Lodge DS0000013572.V306086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given opportunities to improve their lifestyle and are offered a healthy balanced diet. EVIDENCE: The manager stated no resident is in any form of paid or voluntary employment. During discussions residents stated that they choose the activities they like to take part in, which include art, craft, cooking, puzzles, shopping and trips into the local community. Care plans sampled provided evidence that residents attend day centres. On the day of the inspection residents were observed engaged in activities of their choosing, with appropriate support being provided by staff. During the inspection it was observed that the registered person had invested in a very large purpose built activity centre at the rear of the garden. During discussions, the manager and staff stated that residents are very keen to begin using this provision, which will free up part of the home that had previously been used for activities such Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 14 as craft and painting. Residents spoken to stated they were looking forward to using the new activity room. During discussions, staff and residents stated they attend activities in the local community that includes the cinema, shopping, bowling, restaurants, Harlequinn theatre, keep fit, attend church services of their choice, and the local football club. Staff stated this provides residents with opportunities to meet other people from outside of the home. The home has its own transport. During discussions, the manager stated that residents are not able to understand racial and Cultural needs, however, staff are aware through the care plans of the religious needs of residents. The home has a diverse workforce. All residents living at the home are white British. Residents have opportunities for having girlfriends/boyfriends through attending day centres and other external activities. The manager stated residents would be provided with necessary support and advice as and when needed. Parents and families are encouraged to visit the home, and residents have regular contact with their relatives. The home organises an annual family BBQ every year for parents and families, and have a similar event during the Christmas period. The manager stated that some residents are able to have weekend visits with their parents and families. During discussion staff and residents stated they all help with chores around the home. Residents have been offered keys to bedrooms, but all have refused to have these, evidence of which was recorded in their care plans. Staff stated residents receive and make telephone calls in private; there is a telephone in the hallway, and residents can use the home’s cordless telephone in their bedrooms. Staff stated that residents are consulted about the menus. Evidence of this was seen in the minutes of residents meetings. Residents confirmed that they help to choose the menus, and that they could have a different meal if they did not like that day’s meal. Residents stated that they have jobs in the home that they like to do. Menus were viewed and found to offer balanced and appetising meals with fresh vegetable and fruit. Inspection of the kitchen areas found food to be appropriately stored in cupboards, freezers and fridges. Bracken Lodge DS0000013572.V306086.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Physical and emotional health care is offered in such a way as to promote residents independence. The residents are protected by the home’s storage, administering and recording medication policies and procedures. EVIDENCE: During discussions, staff stated that personal support is offered to residents who request it, and by staff of the same sex. Staff stated this is undertaken in a private and sensitive way to protect the dignity of the resident. Personal support is recorded in health care plans and includes help with opticians, vaccinations, skin care, women’s health needs. All support in regard to personal care is recorded. The manager stated residents are consulted in regard to the support they would like in regards to their health care, and which member of staff they would like to help them. Residents’ likes and dislikes were recorded. Consistency and continuity of support is provided to residents through designated key workers. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 16 Arrangements regarding areas of health care are detailed in residents’ care plans. Records of visits by the GP, and attendance to the Dentist, Opticians, Chiropodist, and other health care professionals are also maintained. Residents have access to all NHS healthcare facilities as required. Incidents of illness are recorded in daily records and healthcare plans. All residents have an annual health review on their Birthday. The home has produced a comprehensive Medication Policy dated May 2005, which details clear guidance to all staff who administer medication. The manager stated that two members of staff are present when medication is being dispensed, one member of staff administers and signs the Medical Administration Sheet, the other member of staff signs a separate sheet to state they have witnessed the medication to be administered as per the prescribing G P instructions. Evidence of these records were viewed. Staff confirmed this practice during discussions. The manager stated no resident is currently taking a prescribed controlled drug, and no resident is selfmedicating. Medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained. The home maintains records of medicines received and returned to the Pharmacist. Medication is appropriately stored in a locked metal medical cabinet. Training records, for staff who dispense medication, were viewed. The manager stated the local pharmacist offers advice to the home. The requirement made at the last inspection in regard to medication has been complied with. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues, but policies and procedures must be reviewed. EVIDENCE: The home has a clear Complaints Policy and Procedure dated May 2005. This gives clear procedures and guidance of how to make a complaint, who to complain to, timescale for responding and investigating complaints, and includes the Commission For Social Care Inspection Surrey Local Office contact details. During discussions, residents stated they would talk to staff if they were unhappy or wanted to make a complaint. Staff spoken to stated that they had read and understood the Complaints Policy and Procedure, and gave an accurate account of whom they would report complaints to. Staff stated they would not hesitate in reporting concerns to the Commission For Social Care Inspection Surrey Local Office. The complaints book was viewed and evidenced there had been no complaints made since last inspection. The complaints book details the date, name of the person complaining, nature of complaint, action taken, and the date feedback was provided to the complainant. The home has a Protection of Vulnerable Adults Policy, which is dated May 2005, however, this must be reviewed and updated in line with the Surrey Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 18 Multi-Agency guidelines on the Protection of Vulnerable Adults. During discussions staff gave an accurate account of what to do if they witnessed or suspected that a resident is being, or had been abused. Staff stated they would have no hesitation in reporting bad practice, and if necessary, they would report their concerns to the Commission For Social Care Inspection Surrey Local Office. Evidence of staff training in the Protection of Vulnerable Adults was observed. The manager had attended the Surrey Multi-Agency training in the Protection of Vulnerable Adults on the 29th June 2006. The home has a ‘Whistle Blowing Policy’. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. On the day of the inspection the home was found to be clean, tidy and free from offensive odours. The majority of the bedrooms were bright and airy, and the décor was very nice and fresh. Residents spoken to stated they liked their bedrooms, and had chosen the colours for their bedrooms. All bedrooms visited had window restrictors fitted. The manager stated another bedroom, the first floor bathroom, lounge, conservatory and laundry room are to be redecorated in September when the residents are away for their annual holiday to Hastings. The home has a large garden to the rear of the property, and as stated earlier in this report, the registered person has had a large activity centre built at the back of the garden. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 20 Residents have unrestricted access to the lounges, dining room and garden. Residents were observed using the communal areas during the inspection. The home has an Infection Control Policy that provides guidance on the legal responsibilities, including the handling and disposal of soiled waste, protective clothing, cleaning of spillage, storage, preparation and serving of food and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. During discussions, staff stated they had read all Policies and Procedures written for the home. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 21 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 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s recruitment policy, however, the home must ensure all recruitment files contain the necessary information. EVIDENCE: On the day of the inspection staff were observed to interact with the residents in a professional and caring manner. The relationship between residents and staff was relaxed and friendly. Residents were observed communicating with staff, and being accompanied to activities outside of the home. The home employs eleven care staff, three of which are students who work twenty hours per week. Four staff hold the minimum NVQ level 2, and four staff are currently undertaking either NVQ level 2 or NVQ level 3 training. The registered person is committed to ensuring staff are appropriately qualified. Staff training files sampled evidenced training that had been undertaken. The home has a comprehensive Recruitment Policy and Procedure, which meets with the National Minimum Standards. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 22 Recruitment files sampled, with the exception of one, had all the necessary documentation as required, including proof of identity. It was observed in one file sampled that the employment history part of the application form was missing. A requirement has been made that the manager must locate this, or the member of staff concerned must provide another full employment history. One staff file sampled did not have explanations of gaps in employment. A requirement in regard to this has been made. Evidence of staff receiving induction training was viewed in the staff files sampled. The training and development of staff continues to progress. During discussions staff stated they had received all mandatory training during the last twelve months. Although evidence of training was viewed in staff files, it was noted that staff do not have individual training and development assessment profiles. A requirement has been made in regard to this. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, and the safety of residents is promoted and safeguarded. EVIDENCE: The manager of the home was successfully registered with the Commission For Social Care Inspection Surrey Local Office in June 2006. The manager has 7 years experience working with Learning Disabilities, of which 5 years have been in a senior position. The manager’s qualification includes the NVQ level 3, the Registered Managers’ Award (RMA), and is currently undertaking the NVQ level 4. During discussions, staff stated they have confidence in the manager, that she is approachable and has an open door policy. Residents stated they like the manager and they were observed freely engaging in conversation with her. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 24 The home’s owner continues to visit the home on a regular basis, and conducts Regulation 26 reports, which were evidenced during this inspection. The residents have known the owner for a long time as he used to manage the home. During discussions, residents stated they always talk to the owner, and they enjoy his presence when he accompanies them on both internal and external activities. Quality assurance surveys were viewed. These evidenced that the home’s management seeks the views of residents and staff in regard to the care provided by the home, and future developments within the home. However, it was noted that this has not been extended to residents’ families and/or representatives. A requirement in regard to this has been made. Training files sampled evidenced the following mandatory training had been undertaken: food hygiene and handling, first aid, 4/11/05, Protection of Vulnerable Adults, 9/12/05, health and safety and manual handling, 25/11/05, medication, 2/12/05, and fire safety, 23/5/06. The following health and safety checks of the home were evidenced during this inspection; fire drills, testing and maintenance of fire detection and prevention equipment, legionella, gas boiler, electrical certificate, portable electrical appliance testing, COSHH register, fridge/freezer and cooking temperatures, weekly monitoring of the hot water outlets. The manager was unable to locate the fire risk assessments for the home; these were evidenced during the inspection of October 2005, and were dated 24/1/05. A requirement has been made that the manager must locate the fire risk assessments or make the necessary arrangements to reproduce them. General risk assessments for the home were evidenced during this inspection. Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 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 3 X 3 X 3 X X 3 X Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 26 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 YA23 Regulation 13 (6) Requirement The manager must review and update the Protection of Adults Policy and Procedure to ensure they are written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults. The manager must locate the employment history of one identified member of staff, or the member of staff concerned must provide another full employment history. The registered person must ensure the reasons for gaps in employment are recorded. The registered person must ensure that all staff have individual training and development assessment profiles. The registered person must develop a system to ascertain the views of residents’ representatives in regard to the quality of care they receive. The manager must locate the fire risk assessments or make the necessary arrangements to reproduce them. DS0000013572.V306086.R01.S.doc Timescale for action 14/08/06 2. YA34 19 (1) (b) Sch 2 10/08/06 3. 4. YA34 YA35 19 (1) (b) Sch 2 (6) 18 10/08/06 01/09/06 5. YA39 24 (3) 01/09/06 6. YA42 23 (4) (a) 01/09/06 Bracken Lodge Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI Bracken Lodge DS0000013572.V306086.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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