Inspection on 23/05/05 for Bracken Villa Care Home

This inspection was carried out on 23rd May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bracken Villa Care Home 06/07/07

Bracken Villa Care Home 07/07/06

Bracken Villa Care Home 27/09/05

Bracken Villa Care Home 17/02/05

Bracken Villa Care Home 03/11/04

Bracken Villa Care Home 19/01/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Bracken Villa Care Home 6 Bracken Lane Retford Nottingham DN22 7EU Lead Inspector Jayne Hilton Unannounced 23 May 2005 10:00 rd 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 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 Stationary 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 Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bracken Villa Care Home Address 6 Bracken Lane Retford Nottingham DN22 7EU 01777 719720 01777 719645 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyage Limited, 1st Floor Office Suite, Kelham Street, Doncaster DN1 3QZ James Simpson Care Home (CRH) 8 Category(ies) of Learning Disability (LD) 8 registration, with number of places Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 17/2/05 Brief Description of the Service: Bracken Villa is a detached house, set within its own grounds, close to the centre of Retford. There are also 2 small self contained flats, which provide accommodation for 2 service users who are semi-independent.Car Parking is available on the drive and on the street too. There is a large attractive garden to the rear of the property, which includes a sensory area, developed with input from the residents .Six residents with learning disabilities and challenging behaviour are accommodated in single bedrooms, one of which is on the ground floor, within the main home. All rooms meet with or exceed the size requirements and show evidence of being well personalised and decorated to suit the individual resident. The manager is hoping to proceed with en-suite bathrooms for the bedrooms that this is possible for.The property benefits from a large lounge and separate dining room. In addition, there is a kitchen with a large attached conservatory. The home is well maintained and provides a good standard of homely, comfortable and attractive accommodation in pleasant surroundings. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on 23rd May 2005 for a duration of 5 hours. The methodology used included a tour of the environment, speaking with a group of four residents and three residents were spoken with individually. The manager and two staff were also spoken with. A sample of records was examined including three development plans. Direct and indirect observations were also made particularly regarding staff/resident interaction. The inspection was very positive and it was clearly evident that the support given to service users is of a very high standard. The residents at Bracken Villa preferred term of address in this report is ‘residents’. The Inspector wishes to thank the residents for their hospitality and co-operation during the visit. What the service does well: Residents spoken with said that the best thing about living at Bracken Villa is that it is homely, is an ordinary house and there are no signs. Residents know what their support plan is and understand its purpose, they are involved in the development and review of their support. Reviews are held regularly but also when the need arises. Care plans are presented methodically and are well organised. Residents spoken with feel they are offered plenty of opportunity to participate in the day to day running of the home. Good risk assessments in place for all residents and these are reviewed regularly. Residents are encouraged to develop independent living skills and to take part in community activities and educational opportunities. Residents are encouraged to retain and learn new skills. Residents spoken with stated that they were happy with the meals provided and that they are involved with choosing and cooking the meals. Bracken Villa is a clean and comfortable home. Service users bedrooms are personalised. The provision and maintenance of the staff team, their qualities, qualifications, training and support, meet the stated purpose of the home and the assessed needs of the residents. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 6 The conduct and management of the home, the day to day operations, ethos and quality monitoring are commendable. A staff member commented that she was happy to work at the home and was proud of what is achieved for everyone at Bracken Villa and for others to see this. 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. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 8 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 standard(s) 1, 2, 3,4,5 Introductory visits are seen as essential for all prospective residents. The service user guide is helpful and the contract is clear and terms and conditions are clear and fair. EVIDENCE: An up to date Statement of Purpose and Service user guide was seen in the home. Initial assessments were seen in the three development plans examined and the manager explained the process of assessment regarding a prospective new resident. The manager and staff members spoken with demonstrated the necessary knowledge and skills to work with the residents. Observations of staff/resident interaction were calm and mutually respectful The manager explained how the home’s approach is not to have a set level of staffing but to have some flexibility in this, based on the assessed needs of individuals living at Bracken Villa. There is an updated and detailed written contract and terms of conditions on each resident’s file, which is signed by the resident. It includes the mission Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 9 statement and philosophy of the home and what services are provided and what is not included in the fee. Introductory visits are seen as essential for all prospective residents. This practice is regarded by the manager, as not only important for resident deciding to move to Bracken Villa but it also gives residents already living at the home the opportunity to meet someone who may be moving into their home. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9,10 Residents know what their support plan is and understand its purpose, they are involved in the development and review of their support. Reviews are held regularly but also when the need arises. Care plans are presented methodically and are well organised. Residents spoken with feel they are offered plenty of opportunity to participate in the day- to- day running of the home. Good risk assessments in place for all residents and these are reviewed regularly. EVIDENCE: Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 11 All of the residents spoken with were familiar with their development plan and contribute to the review process, Clear evidence was seen of their contribution within the plans. The plans were, noted to be, reviewed, appropriately. Care reviews are held regularly which involve social workers and CPN’s [Community Psychiatric Nurses] as necessary. The development plans were presented methodically and are well structured. Residents have an allocated key worker There are individualised procedures for any potential aggressive behaviour. Residents confirmed that they are involved in most things to do with the responsibility in ensuring that the environment is clean and tidy. Various rotas were observed for tasks such as cleaning the minibus and housework. A resident had recently decorated a vacant bedroom. There are fortnightly residents meetings and this time is for anything the residents wish to discuss, including the opportunity to discuss issues regarding the day- to -day running of the home. One resident who had not been able to attend a recent meeting, had been, updated by staff, on what had been discussed. Minutes are taken and these are available. Information on advocacy groups was noted on the notice board. There were good risk assessments within the development plans, which had been reviewed regularly. There are procedures for unexplained absences on each individual residents file. All staff sign confidentiality statement on recruitment and a statement on confidentiality in the service users guide reassures residents that any data kept about them is protected. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12, 13, 14, 15, 16, 17 Residents are encouraged to develop independent living skills and to take part in community activities and educational opportunities. Residents are encouraged to retain and learn new skills. Residents spoken with stated that they were happy with the meals provided and that they are involved with choosing and cooking the meals. Family, friends and partners can visit any time and are made to feel welcome at the home. EVIDENCE: Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 13 It is culture in Bracken Villa that the residents share responsibility for different household tasks. Thus, encouraging independent living skills. One service user was observed cooking the mid-day meal with support from a staff member. Two residents live in their own independent living flats and are working towards living independently. They explained to the inspector how they take the temperature of the fridge and kept their flats clean and tidy. Both were immaculate and the residents proud of their achievements and opportunities. One service user explained his goal was to leave Bracken Villa at the end of the year to live independently. Residents spoke about doing the cleaning and taking it in turns to cook the evening meal. There is also a monthly kitchen rota, which includes loading and unloading the dishwasher. Some residents are under guardianship orders under the Mental Health Act and therefore restrictions are imposed regarding this and are documented. Residents go out to college and also have opportunities to mix with other people, not just those they live with. If they choose to residents can attend the local college. Some of the residents had undertaken NVQ in Bird Care. It was evident from discussion with both service users and staff that access to and participation in the local community is actively promoted. A full and varied programme of activities was displayed which included, bike riding, bowling, horse riding, five a side football, monopoly, bingo, boules, quiz, and treasure hunt. Community facilities such as the swimming baths and bowling alley are regularly used and enjoyed by the service users. Residents confirmed they use their right to vote. A quiet garden area has been created by residents and staff and there are plans to introduce an aviary and guinea pigs. Residents were observed attending to the fishpond and maintaining the area. A resident told the inspector that they had built relations with a neighbour and had carried out some work for him in the garden. Residents also informed the inspector of a cheese and wine party they organised and invited the neighbours. A resident informed the inspector that he had bought some golf clubs from a car boot sale and suggested that he create a crazy golf course on the lawns. In house entertainment systems were provided in the main lounge, such as a wide screen television, music centre, DVD and SKY television. A ‘rec room’/social club room is provided which is equipped with appropriate recreational equipment and residents can purchase sweets, and other provisions from the shop facility. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 14 It is evident that staff support residents to maintain family links and friendships. The manager and residents spoken with confirmed this. The home has its own transport, which has provided residents with more opportunity to meet up with family and friends. Family, friends and partners can visit any time and are made to feel welcome at the home. From observation, it was evident that all staff respect residents right to privacy. Residents were observed using keys to their rooms. Lockable facilities were available in the rooms. The atmosphere in the home was relaxed and staff and service residents were seen engaging and interacting with each other. Residents confirmed that mail is given to them unopened. The residents preferred term of address was not seen on any of the development plans, this should be discussed with them and rectified. The term ‘lads’ was used, by staff to describe the residents and the inspector discussed this with the residents and the appropriateness of this term in relation to their age. There was some objection raised to the term and it was suggested that the group discuss the issues in their residents meeting and with staff. One resident has a monitor alarm in his room to assist staff support for his epilepsy, however this is not documented on the individuals development plan. There was a good and varied stock of food seen in the home. With assistance from staff, residents organise a weekly menu plan and residents confirmed they take it in turns to cook the evening meal, with support. The menu is recorded on flip chart in the dining room so all residents have a say in what meals are provided. The menu’s seen showed nutritious, varied and balanced meals. Residents confirmed that are also involved in the purchasing of food by going along with a member of staff to the supermarket. [ care should be taken regarding stock rotation and use by dates particularly, of herbs and spices] There is usually a monthly trip out to a local restaurant for a meal. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20, 21 The healthcare needs of residents are generally being met and there are systems in place for monitoring health needs, including behaviours in place The resident’s wishes regarding death and dying recorded and are very detailed and residents are, protected by, good management of medicines in the home. EVIDENCE: All of the residents spoken with are fully aware of what their development plan is and what is its purpose. Residents spend allocated time with their key worker each month to reflect back over the previous month. This is an opportunity for residents to be involved in the reviewing of how their personal support is provided. The home maintains good links and relationships with necessary resources such as Community Learning Disability Teams and community psychiatric nurses. From talking with residents and staff it was apparent that personal support is flexible and the overall culture of the home is to promote choice, control and independence. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 16 The current system for documenting healthcare checks means that information is archived and it is recommended that a running history be kept on each health need, such as chiropody, dentist, GP, annual well person checks etc. The system would ensure that information is at hand and that regular appointments are not overlooked. Staff can use to reference and pattern any re-occurring or ongoing health issues There are good methods for monitoring. One resident who has epilepsy has a monitoring record for seizures, which makes this information more accessible than if it was just recorded on daily records. An assessment was made of the management of medicines in the home. Staff who dispense medication are trained in house by a qualified nurse and by Boots. Competency assessments are carried out. It was reported that no Controlled medicines are currently used in the home. Policies for medicines management are kept in the office and it is recommended that copies of these be kept with the medication. The drug error policy should be sited where staff can instantly access this and should inform staff that any errors in medication procedures must be reported to CSCI under regulation 37 requirements. The staff member spoken with was unaware medicines must be kept for 7 days after the death of a service user. There was excellent medication overview information on each resident taking medication in the medicines cupboard, copies should be transferred into development plans in creating a medication profile and record of medication reviews and changes to medication. Residents confirmed that they sign for medication when dispensed by staff as a double signature. There is a written policy and procedure available within the home dealing with increasing mental and physical frailty. The policy indicates that residents would be supported to remain at the home for as long as they wish and is reasonably practicable. The staff have gathered a great deal of information from the service residents regarding their wishes concerning illness and death, this is now detailed in each care file. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 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 standard(s) 22, 23 The home has a complaints policy which, residents are aware of and know how to use. All complaints are responded to within 1 working day and concerns expressed are also recorded. The appropriate policies and procedures for dealing with abuse are in place. EVIDENCE: There is a book for which all concerns and complaints are recorded in, including if and what necessary action has been taken. There were no concerns recorded since the last inspection. It was evident from discussion with the manager and staff that all concerns and complaints are taken seriously and responded to (within 1 day). The residents spoken with are all fully aware of the complaints procedure and one service user showed me his complaints procedure, which is framed and displayed in his bedroom. All information on the procedure is up to date and includes how to contact the Commission for Social Care Inspection. The home holds the Nottinghamshire Committee for the Protection of Vulnerable Adults Policy and procedures for dealing with suspected abuse. [It is recommended that the manager checks the folder has appropriate up to date information regarding reporting procedures and is advised to speak with the Adult Protection Unit regarding this] There are also procedures for positive intervention to behaviours that challenge. Staff are trained in de-escalation techniques and adult protection. A policy for whistle blowing was seen. All service users have their own bank accounts.[Financial records were not inspected at this visit] Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29, 30 Bracken Villa is a clean and comfortable home, which provides adequate communal space. Service users bedrooms are personalised. The toilet and bathroom provision is adequate but could be improved by further en-suite provision. The service users independence is maximised by the facilities and equipment in the home. There are some areas, which need addressing to ensure overall safety and security of residents and their possessions. EVIDENCE: Bracken Villa is a detached house, set within its own grounds, close to the centre of Retford. There are also 2 small self contained flats, which provide accommodation for 2 service users who are semi-independent.Car Parking is available on the drive and on the street too. There is a large attractive garden to the rear of the property, which includes a sensory area, developed with input from the residents . Six residents with learning disabilities and challenging behaviour are accommodated in single bedrooms, one of which is on the ground floor, within the main home. All rooms meet with or exceed the size requirements and show evidence of being well personalised and decorated to suit the individual resident. The manager is hoping to proceed with en-suite Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 19 bathrooms for the bedrooms that this is possible for, which would further improve the promotion of privacy and dignity for individuals.The property benefits from a large lounge and separate dining room. In addition, there is a well fitted and equippedkitchen with a large attached conservatory. The home is well maintained and provides a good standard of homely, comfortable and attractive accommodation in pleasant surroundings. Bedrooms seen were very personalised with service users own furniture and chosen décor, including personal photos, artwork and posters etc. The home has sufficient bathrooms and toilets. The ground floor bedroom now has an en-suite facility to meet the needs of the service user, There were a number of radiators, which were not covered, those in bathrooms pose a risk and must be covered. Attention to the floor covering in the brown bathroom is needed, as it is at risk of lifting and may cause a trip hazard if not secured. From observation and being shown around the home, the premises appeared clean, hygienic and free from offensive odours. Extra care should be taken regarding the build up of mildew in shower areas and ensuring that disposable gloves are available in the laundry room and liquid soaps are provided in all bathrooms etc. Laundry facilities are sited appropriately to prevent risk of infections and washing machines have the specified programming ability to meet disinfection standards. The operations manager for the organisation was undertaking an audit visit on the day of the inspection and therefore some record checks were not duplicated such as fridge/freezer and food probing records. [Care should be taken to ensure that staff and residents remember to wear aprons when preparing and serving food] In the independent living accommodation, the fridge temperatures were methodically taken by, the residents living there and records were seen. The independent living flats were both kept immaculately clean and the residents are commended for this. There was concern regarding the lack of window restrictors in the service users bedroom areas, which are a security risk as the windows are placed adjacent to the door. An immediate requirement was made for window restrictors to be fitted, which will allow appropriate ventilation but prevent access to the door opening mechanism. This must be carried out within 14 days. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33,34,35,36 Robust recruitment practices and the provision and maintenance of the staff team, their qualities, qualifications, training and support, meet the stated purpose of the home and the assessed needs of the residents. EVIDENCE: The rota appeared to show adequate staffing on each shift. The manager explained how staffing is not set in stone but is flexible around the varying needs of the service users living at Bracken Villa. The manager reported that recruitment had been more difficult recently and that this was probably due to local competing services in the area. The provision of overtime ensures consistency within the team. Residents expressed that they did feel there community activities had been affected as new staff were prevented undertaking certain activities until they had achieved appropriate training. Residents stated it seemed there was unnecessary delay on occasions in the provision of the training. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 21 The home follows the recruitment policy and procedures as defined by Voyage Limited, the organisation that Bracken Villa is part of. A sample of personal files were examined and found to be satisfactory. Residents spoken with said that when prospective members of staff come to the home for interview the residents get the chance to meet the interviewees and give their opinions on them. Staff spoken with said that they receive good support and supervision and training opportunities are very good. Staff files indicate that supervision is given bimonthly. The manager and team leaders act as supervisors. From discussion with staff it is apparent that staff are interested, motivated and committed to the work they do and more specifically, the service they provide at Bracken Villa. Staff development is encouraged at Bracken Villa and the necessary training to ensure that staff have the skills and competencies required to meet service users’ needs is identified in individual’s appraisals. The training records examined confirmed this. Every 3 months staff, are expected to revisit and monitor the objectives set in their annual appraisal. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, 42, The conduct and management of the home, the day to day operations [including health and safety standards], Policies, procedures, record keeping, ethos and quality monitoring are commendable. EVIDENCE: The manager is a registered nurse and has managed services for a number of years. The manager has now completed the NVQ level 4. Residents and staff made positive comments about the manager, for example, residents said” Jim is a cracking man, the residents think he is fantastic, he’s a good leader for the staff”. Staff comments included, “ Jim is a good mentor he has good leadership skills, is a good listener, is a good problem solver, is calm and demonstrates objectiveness” Staff also added “there are good systems in place”. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 23 The tier system for staffing at Bracken Villa was introduced by the manager and works very well. Below the manager are 4 team leaders, next are shift coordinators and then there are support workers. The manager ensures tasks are delegated appropriately. This has encouraged staff to improve their own practice and to develop knowledge and skills. This clearly benefits Bracken Villa but is also to enable senior staff to move on and manage other homes. This foresight and investment in staff is to be commended. Minutes of various meetings were examined, team leader meetings, staff briefings, staff meetings and night staff meetings. Voyage Limited has its own quality assurance system. Service user surveys are done every 6 months and audits are carried out regularly. The fortnightly residents meetings also act as a method of collecting information for quality assurance purposes. The manager has also devised a quality monitoring tool, which he uses for auditing practices within the home. This was examined at the inspection. Regulation 26 visits and reports are provided monthly. All records seen during the inspection are maintained, up to date and accurate. The home has a good system for archiving records and ‘filtering’ information from the current development plan. Accident records are kept on individual service resident’s files. All records are kept secure. Evidence of mandatory training provided on induction and as refreshers was seen Fire tests and drills are carried out as often as they should be. On inspection of premises products falling under COSHH [Control Of substances Hazardous to Health, were stored securely. One member of staff takes responsibility for ensuring the correct data is kept on this topic. Risk assessments for safe working practice topics were seen to be in place The health and safety poster was noted to be out of date and was promptly corrected when this was pointed out at the inspection. Water outlet testing records were excellent, a sample of water outlet temperatures were tested and found to be satisfactory. The manager reported that a check for leigionella prevention, had been carried out the week previous and that a copy of the certificate will be faxed to the inspector when received. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 4 4 4 4 3 2 3 Standard No 31 32 33 34 35 36 Score 4 4 4 3 3 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bracken Villa Care Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 4 3 x C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 23 Requirement Ensure window restrictors are fitted to the windows in the self contained acommodation which will allow ventilation yet provide security of access from the outside. An immediate requirement was set at the inspection for this to be carried out within 14 days] Ensure radiator covers are fitted to high risk areas such as bathrooms and risk assess other radiators throughout the home. Timescale for action 8th June 05 2. 24 23 23rd July 05 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. 2. 3. 4. Refer to Standard 3 16 16 17 Good Practice Recommendations Ensure residents prefered term of adress is documented within individual plans Discuss the appropriateness of group term used in the home lads and document the outcome. Where monitor alrams are used, the reason must be documnted within the development plan. Delegate responsbility for stock ratation and use by dates of food stocks. C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 26 Bracken Villa Care Home 5. 6. 7. 8. 9. 10. 11. 12. 19 20 20 24 27 30 30 35 Incororate running history sheets in development plans for all healthcare checks for easy reference and evaluation of whether healthcare needs are being met. Site the drug error policy, where staff can access it instantly. Use the medication profiles in the development plans and include details of medication reviews and changes of medication. Make regular checks on the flooring in the brown bathroom regarding the potential trip hazard. Provide ensuites to bedrooms where space allows Delegate responsibility to ensure that stocks of disposable gloves and liquid soaps are provided at all times in the appropriate rooms. Provide reminders for staff and residents to wear aprons when preparing and serving food. Consider residents comments regarding training delays and action accordingly. Bracken Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Villa Care Home C53 C03 S8635 Bracken Villa V228994 230505 Stage 4.doc Version 1.30 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!