Inspection on 03/09/07 for Bracken Lodge

This inspection was carried out on 3rd 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bracken Lodge 01/08/06

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 Suzanne Magnier Unannounced Inspection 3 September 2007 09:30 rd Bracken Lodge DS0000013572.V344602.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.V344602.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.V344602.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.V344602.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. The property is two semidetached houses that have been joined together. Care and accommodation is provided for up to ten 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 individuals to use. The home has a large conservatory, which is used as a dining room and activities area with an additional chalet in the large wellmaintained rear garden where individuals can have leisure and activities. Car parking facilities are available to the front of the home. The fees range from £600 to £800 per week. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Following the previous key inspection in August 2006 the service has met all the requirements made. Ms S Magnier Regulation Inspector carried out the inspection and deputy and registered manager represented the service. For the purpose of the report the individuals using the service are referred to as people or individuals. The inspector arrived at the service at 09.30 and was in the home for five and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking and observing people living at the home in order to seek their views about the home and the care they receive. Responses to comment cards that the Commission received included ‘ to know my relative is safe and being well cared for is a huge relief’ ‘ I speak to the manager at least once a week’. ‘All round care is excellent and I feel very lucky that my relative has a place in this home, his life has turned around and he is very happy now.’ ‘It is a very well run home and I wish there were more homes about like this’. ‘The home is always clean and tidy, they ferry the residents daily to a centre, take them on an annual holiday. The staff are charming and loved by the residents’. ‘ I believe this to be a good care home I see it from the day service point of view. The care seems good and service users are happy’. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care/person centred plans, risk assessments, medication procedures, staff files, a variety of training records, and several of the services policies and procedures. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 6 From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. What the service does well: What has improved since the last inspection? What they could do better: It has been required that some amendments need to be made for example the new contact details of the Commission for Social Care Inspection (CSCI), the inclusion of the homes external chalet, the number of staff working at the home and some outdated terminology. During the sampling of the care plans the inspector noted that a further development with regard to peoples care plans would be to include more focus on individuals skills regarding their abilities to assist in their personal care and Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 7 participating in the running of their home in order to monitor and maintain peoples skills and abilities. All parts of the home must be kept in a good state of repair both internally and externally, are reasonably decorated, suitable lighting is provided in all parts of the home and adequate furniture is provided to individuals. 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. Bracken Lodge DS0000013572.V344602.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.V344602.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People and their representatives have information about the home in order that they can make an informed choice about moving to the home however some information needs to be updated. The homes admission and assessment procedures ensure that individual’s needs are appropriately identified and met. Terms and conditions/contracts of stay at the home are available to all individuals. EVIDENCE: The home has a statement of purpose, which was sampled by the inspector. It was noted that the document was well written. It has been required that some amendments need to be made for example the new contact details of the Commission for Social Care Inspection (CSCI), the inclusion of the homes external chalet, the number of staff working at the home and some outdated terminology. The manager has updated the service users guide using pictorial forms, which are interesting and engaging which would assist people to make a choice if they want to live in the home. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 10 There have been no admissions to the home since the previous inspection yet comments received on the day of inspection from some people at home and also written comments included ‘‘Nice place I like it here’, ‘Bracken Lodge was chosen for my relative because it is small in numbers but appears to be like a large family unit. The staff are caring and concerned regarding the residents welfare’ ‘I like staying here cos its more better than there cos you look after me and I tried it first’, ‘I like it best here I cant move because I’ve got my pictures’ The inspector sampled a needs assessment form, which was noted to be comprehensive in ensuring that a full assessment would be undertaken prior to individuals moving into the home. The manager demonstrated that she was knowledgeable regarding the criteria and the importance of individuals needs assessment prior to admission in order to ensure that the home could meet the needs and aspirations of the individual. The inspector sampled several tenancy agreements for people in the home and noted that they had been signed and were located in their personal files. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home have improved the documentation and management of peoples care plans and risk assessments to clearly demonstrate that their health, personal care and safety are being met. Individuals are encouraged to make decisions about their lives both inside and outside of the home. Developments regarding documenting individuals abilities and maintaining skills need to be more fully developed. EVIDENCE: The manager and staff have made a significant effort to improve the care plans for all people in the home and part of the improvement has been the use of pictures/icons. The two care plans sampled by the inspector were well written and clearly detailed the support needs and lifestyles of the individuals. The care plans included a positive photograph of the individual and documented their likes, dislikes, preferences, social and cultural history dreams and aspirations which offered the reader an insight into the individual’s life. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 12 A written comment from a health care professional included ‘I feel that all efforts are made to encourage and support my client to make confident choices.’ In the main people are treated with respect and humour, my client has had opportunities to dress well and feel proud of how they present themselves.’ During the sampling of the care plans the inspector noted that a further development with regard to peoples care plans would be to include more focus on individuals skills regarding their abilities to assist in their personal care. Whilst there was documentation to state that people could help to assist there was no documentation to support that this ability was being monitored and maintained. There was evidence that the manager and staff regularly reviewed the care plans to ensure the changing needs of individuals are recognised and arrangements made to meet peoples changing needs. This was evidenced with one person who had returned home from hospital whose needs had changed and were being catered for by staff along with the support of the district nurse and other health care professionals. Throughout the home the inspector observed that people expressed their choices in their own ways and people moved freely around their home. Staff were seen to be attentive and on hand if they were needed. One person told the inspector that they liked to read their newspaper and special magazine, others had been supported to attend activities in the community, one person with the support from another individual were watching a video. Several individuals told the inspector that they had chosen to go on holiday and it was noted that some people had already packed their suitcases in anticipation. The inspector sampled a variety of risk assessments, which were well documented to include all aspects of individual’s lives where hazards to their safety had been identified. All the risk assessments had been signed and were current documents with ongoing review dates. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home promotes and maintains people’s involvement in their local community, offers opportunities for personal development, appropriate activities and assists in maintaining and supporting friendships. Improvements are to be made to encourage people to be more involved in the running of the home and maintaining their daily living skills. A choice of a healthy diet is provided. EVIDENCE: The inspector met with all the people at home. The atmosphere in the home during the day was calm and peaceful. Some people told the inspector that they were looking forward to going to Centre Parks for their holiday and told the inspector other things that they liked to do both at home and at day centres or college which included pottery Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 14 classes, bingo, music sessions, art therapy, kitchen skills, music therapy, growing plants, darts and pool in the chalet, attending meaningful activities at the deaf association, crafts, going shopping and attending places of worship. One person showed the inspector a plant arrangement and the manager explained that a local college had arranged a tailor made course for the person to attend as they enjoyed working with plants and flowers. Written comments from people living in the home included ‘I like to read my newspaper and write. In the evening I like to watch TV, at weekends I go out in the minibus for a drive if they are going out’; ‘I like going out in the minibus, I like the dinners and like playing football and going for walks’. Everybody treats me well’. Whilst touring the premises the inspector observed that one person had a hobby, which included an interest in the police force and the staff explained that the local police had offered visits and given the individual several items of interest to support their hobby. It was evident that despite the number of people living in the home the staff and managers had maintained and promoted peoples individuality. Comments received from visitors to the home included ‘through careful support and respect my client has discovered a new sense of privacy and dignity, that they had lost prior to moving to Bracken Lodge. The manager has been sympathetic to the subtleties of some of the underlying needs of this person and everyone agrees that their life has turned around in the most positive way since their move’. During the inspection the inspector observed that one person’s relative telephoned and spent a lot of time talking with a staff member (as the person living in the home was asleep). It was apparent from the conversation that the home had maintained a close bond with the relative. During the inspection the inspector noted that people chatted between themselves and appeared relaxed and happy in the home. Written comments from visitors to the home included ‘one is always made to feel welcome whether visiting unannounced or having made prior arrangements. Refreshments are always offered to me when visiting. Telephone calls to the home are answered politely and messages relayed if necessary’. During the sampling of the care plans the inspector noted that a further development with regard to peoples care plans would be to include more focus on individuals daily living skills in order to promote further engagement and achievement. It was noted that individuals had a variety of skills which included helping each other, reading, writing, flower arranging and making cups of tea with support yet there was little documented evidence to support how the peoples abilities or daily living skills could be maintained and improved. A written comment from a healthcare professional included ‘There are always going to be some disadvantages of a large group home e.g. possibilities for flexible meal times and clients preparing their own meals.’ Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 15 It has been recommended that the documentation of people’s goals and aspirations be more fully developed in order that people skills are recognised, maintained and further developed for example people participating in the running of their home. Several ideas were discussed with the manager who was open and enthusiastic to the ideas, which could include individuals wiping the table after meals, wash their mugs up after their tea and supper, light hovering, dusting, cleaning their bedrooms and polishing. The inspector sampled the homes menus, which indicated a varied diet. Vegetarian dishes as well as meat dishes and a variety of multi cultural dishes and healthy options were available. The inspector observed the lunchtime meal being served by staff to individuals seated in the conservatory/dining area. The meal was pleasantly presented and staff were observed to be on hand to support one person with their meal in a manner, which engaged the individual and supported them with dignity. Some individuals told the inspector that they can choose what they want to eat. The homes fridges and freezers contained had a variety of foodstuffs and a variety of diary products. Fresh fruit and vegetables were also available. The inspector noted that in the homes refrigerator several opened packages food and pastes were open and had not been labelled at the time of opening. This was brought to the deputy managers attention who explained that the home had tried to manage the issue yet one individual living in the home often opened foodstuffs from the fridge despite having their own fridge in their room. The deputy manager discarded the unlabelled foodstuffs immediately at the time of the inspection. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home has documentation to evidence that people receive personal care in the way they prefer and attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are robust to ensure the safety and wellbeing of all people in the home. EVIDENCE: The two care plans care plan sampled contained clear documentation regarding the ways in which the person has their personal care needs attended. Preferences were noted with regard to gender specific care, choice with regards to clothes and their freedom to move around in their home. The care plans also included a pictorial health care booklet and checklist, the persons body weight chart, clear records of health care appointments attended for example GP, optician, dentist, chiropodist, specialist health care professional reports and records to indicate that care plan reviews had taken place. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 17 The manager explained that some additional health care needs had been identified for some individuals and these had been addressed with a variety of health care professionals including physiotherapy, occupational therapists, speech and language therapists and peoples care managers. The inspector was advised that staff had undertaken specialist training to support an individual with PEG feeding and the district nurse was available to the home should any concerns arise. The manager advised that one person had a profiling bed and this had been risk assessed including the use of bed rails to ensure the safety and well being of the individual. Written comments received from healthcare professionals included ‘the home are very good at reviews, health care needs are always discussed. Very caring home’, ‘ I have been very impressed at the way the homes management have addressed an urgent need to improve the health care of one person and has successfully liaised with the care managers and other professionals.’ ‘There is good liaison with the GP and community team as well as peoples needs being considered and met by the Bracken Lodge staff.’ The home has a comprehensive medication policy and procedure regarding administration of medication. The home has a Monitored Dosage System (MDS) system, which is overseen by the managers. The home have a robust recording system of medication brought into the home and returned to the dispensing pharmacy. The home has medication stored in a secure cabinet. The home works closely with the local pharmacist and the manager explained that all staff had had medication training and there are clear lines of accountability in place regarding the administering of medication in the home, which includes two people one of whom is a witness to medication being administered. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The homes complaints procedure was accessible to people if they wanted to express their concerns about any dissatisfaction. People are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure. No complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. The AQAA details that no complaints have been received since the last key inspection. Comments received regarding how and if people knew how to make a complaint included pointing to pictures of policemen on the wall and stating that they would tell people at the day service, ‘ I go to the manager and tell her what the problem are and she would listen to what I have to say and write it down then deal with the complaint’. The manager demonstrated that she was aware of the local authorities multi agency procedures for safeguarding adults and advised that the home follows these procedures. The AQAA details that there have been no safeguarding referrals under these procedures since the last inspection. The inspector noted that the home has a safeguarding adults procedure which has recently been updated and a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 19 Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults and the inspector. The manager advised that she felt confident to present in house safeguarding training to all staff and this would be implemented should the need arise. Staff training records detailed that staff had received safeguarding vulnerable adults training and where one staff had not attended the training plans were in place for the staff member to attend training in order to safeguard people in their care. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26,27,30. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The home was homely and comfortable in several areas however improvements need to be made to the general decoration and repair in communal and some individual’s private space. Individual’s rooms reflected their individuality. Communal areas, including bathrooms in the home were spacious and met the current needs of the individuals. EVIDENCE: The home continues to offer a homely and comfortable environment however during the inspection the managers recognised that there were areas in the home, which required redecoration and repair. Written comments and peoples comments at the time of the inspection included ‘adaptations to the garden e.g. new out building have given extra space and privacy/quiet etc.’ ‘I am happy here I like my room’. The areas of note of repair were several fire doors, which were not closing correctly, these were repaired throughout the inspection and CSCI informed by Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 21 electronic correspondence the morning after the inspection that all fire doors had been checked and all were closing appropriately. Other areas needing attention were the ill fitting flooring in the upstairs bathroom, the carpet in the shared room was noted as frayed, the stairwell carpet was frayed and the lighting in the shared room needed to be improved (the managers advised that the large outside was due to be cut down which would offer more light), the kickboards in the kitchen were broken and damaged, the skirting board and area by the bin was unhygienic with food splashes, (this was cleaned by a staff member during the inspection) the work surface seals by the gas cooker in the kitchen needed replacing as they were soiled and worn, debris including household furniture by the side of the home needed to be removed to enable clear access from the building in the event of an emergency (the inspector was advised that a skip was going to be ordered) and a chest of drawers needed the handles to be replaced and the drawer of a person’s wardrobe in their room was broken and found in the bathroom cabinet. It was evident that the home was aware that the general standard of repair/decoration and suitable furnishings was in need of attention as the inspector was shown a maintenance/decoration plan, which included the above items and a variety of other areas of the home, which needed attention. The inspector was advised that it was planned to undertake the maintenance programme when the majority of individuals were on holiday. It has been required that all parts of the home must be kept in a good state of repair both internally and externally, that all parts of the home are reasonably decorated, suitable lighting is provided in all parts of the home and adequate furniture is provided to individuals. Details of the completed maintenance programme must be sent to the local CSCI office. One person told the inspector to see their room, which had been recently decorated and they had chosen the colours. In each of the bedrooms there were personal possessions, furniture and leisure items which included televisions, music and photos. The home has several bathrooms some of which had been decorated to make a more homely experience for individuals in the home. The manager explained that there was consideration that one of the baths be changed to a walk in shower as individuals preferred to have showers rather than baths. Staff confirmed on two occasions that the home has a safe bathing policy, which includes water outlet temperatures being recorded and water tested before individuals enter the bath. The two lounge areas have comfortable sofas and adequate seating for people to use and receive their visitors. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35, Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are skilled and in sufficient numbers to provide 24-hour support to the individuals living at the home. Documentation was available to evidence that the home has a robust system for the induction, training development and recruitment of staff to ensure the peoples needs are met appropriately and safely. EVIDENCE: Comments received by the commission regarding the staff team included ‘the staff team are very welcoming at Bracken Lodge, both to visiting professionals and relatives’, ‘the staff are charming and loved by the residents’. The home operates a flexible rosta, which reflects the lifestyle and needs of the individuals and has been adapted to suit people’s needs over the weekends if they wish to go out. The staff team comprises of 12 staff with a multi cultural background. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 23 The records seen by the inspector indicated that all staff had received mandatory training and where refresher courses were needed these had been identified by the manager on the staff training log. The inspector sampled one staff member’s file, which indicated they were a student working 20 hours per week and 40 hours during the term holidays and had undertaken a face-to-face interview. All records were in place including a current CRB clearance. The staff member had undertaken a thorough induction programme, which they had written in full and was noted as an exemplary piece of work in order to understand the support needs of the individuals in their care. The AQAA identifies that 80 of staff are currently involved in achieving or have achiecved their National Vocational Qualification in Care (NVQ) awards. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The overall management of the home is robust, individuals and their representative’s views and opinions are considered and individual’s safety and welfare is well managed. EVIDENCE: Comments received regarding the management of the home included ‘very good manager always very supportive, they keep in touch with the day services very well’ ‘The manager has always taken time to explain and to listen. She is genuinely interested’. ‘Very good timekeeping and efficient admin/messages etc’. Staff spoken with during the inspection spoke favourably of the manager. It was noted that the manager had good knowledge about managing the care Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 25 home and had the skills and experience to ensure the safety and well being of all persons in the home and worked cooperatively with the commission throughout the inspection. The pace of the home was well managed and designed to meet the needs of the people. The manager has attained her Level 4 National Vocational Qualification (NVQ) and Registered Managers Award. The inspector sampled a variety of health and safety records, which included fridge and freezer temperatures, food serving temperatures, water temperature records, accident and incident records, fire drills, practices and general maintenance records. The manager advised that the last environmental health inspection was in November 2006. Hazardous substances were secured in the home and risk assessments had been completed and updated regarding the storage of hazardous substances. Hand washing facilities were available throughout the home and clinical waste disposal appropriately managed. The manager explained that the home had undertaken some quality assurance with some people and their representatives in the home and the inspector noted that the surveys were designed in pictorial form. The responses to the surveys were favourable from the individuals living in the home. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 X 30 2 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 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.V344602.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 4.(1)c Requirement Timescale for action 03/12/07 2. YA24 YA30 The Statement of Purpose needs to be amended to include the new contact details of the Commission for Social Care Inspection (CSCI), the inclusion of the homes external chalet, the number of staff working at the home and some outdated terminology. 16.(2)c All parts of the home must 23.(2)(b)(d)(p) be kept in a good state of repair both internally and externally, are reasonably decorated, suitable lighting is provided in all parts of the home and adequate furniture is provided to individuals. 03/11/07 Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 28 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 YA6 YA16 Good Practice Recommendations It has been recommended that a further development with regard to peoples care plans would be to include more focus on individuals skills regarding their abilities to assist in their personal care and participating in the running of their home in order to monitor and maintain peoples skills and abilities. Bracken Lodge DS0000013572.V344602.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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