Inspection on 06/07/07 for Bracken Villa Care Home

This inspection was carried out on 6th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bracken Villa Care Home 07/07/06

Bracken Villa Care Home 27/09/05

Bracken Villa Care Home 23/05/05

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 Key Unannounced Inspection 6th July 2007 10:00 Bracken Villa Care Home DS0000008635.V340625.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 Villa Care Home DS0000008635.V340625.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 Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bracken Villa Care Home Address 6 Bracken Lane Retford Nottingham DN22 7EU 01777 719720 01777 719645 jimstusimpson@aol.com 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) Voyage Limited James Simpson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2006 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. Fees range from £1,110.40-£2,215.31 Residents are expected to pay for hairdressing, nail care, major outings and holidays etc in addition to this fee detail obtained from staff at the home at 6th July 2007 at the inspection Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 6 daytime hours and was unannounced. The main method of inspection used was called ‘case tracking.’ This involves selecting two residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Various records were looked at including the medication policies, duty records, employment files and training files. Four members of staff were spoken with as part of this inspection, documents were read and medication records inspected to form an opinion about the quality of the care provided to residents. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and an Annual Quality Assurance Assessment questionnaire completed by the registered manager. Nine completed residents/representatives satisfaction questionnaires were also received prior to this inspection. 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 once again. What the service does well: 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 well organised. Residents spoken with feel they are offered plenty of opportunity to participate in the day-to-day running of the home. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 6 Good risk assessments in place for all residents and these are reviewed regularly. The residents spoken with confirmed that they were generally happy at Bracken Villa and that the staff team had enabled them to develop skills and had provided opportunities they would not necessarily have had anywhere else. Clearly Bracken Villa is unique service, which balances a structured environment with the promotion of rights, respect and responsibility in meeting resident’s needs. 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. The Health and Safety of residents and staff is promoted and protected. What has improved since the last inspection? One communal bathroom has been refurbishmed. The loose and eneven paving on the patio have been made safe. The storage temperatures of the medication are now monitored. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bracken Villa Care Home DS0000008635.V340625.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 Villa Care Home DS0000008635.V340625.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, and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where to live and know that their needs and aspirations will be assessed and met within the constraints of the service provided. EVIDENCE: Residents have their own copy of the service user guide however not all residents felt that they had been given the full information about the home prior to moving in to help them decide if the home was the right place for them. The Statement of Purpose and Service user guide are available in large print and picture formats. Initial assessments were seen in the two development plans examined and the manager explained the process of assessment regarding when a new resident comes along. 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 DS0000008635.V340625.R01.S.doc Version 5.2 Page 10 The 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 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 statement and philosophy of the home and what services are provided and what is not included in the fee. The assessment and personal profile documentation included information about the resident’s religious needs and ethnicity but it should be further developed to encompass equality and diversity in more detail. There should also be a section addressing the capacity to consent of individuals. Training provision for staff in promoting equality and diversity and sexuality and relationships is recommended. Bracken Villa Care Home DS0000008635.V340625.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): 6,7,8 an 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are well organised. Residents 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: 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. Person centred plans are being developed with residents and an example viewed were excellent. Care reviews are held regularly which involve social workers and CPNs [Community Psychiatric Nurses] as necessary. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 12 The development plans were presented methodically and are well structured. Key support staff presents an overview of resident progress for discussion in team meetings by which all staff can contribute ideas and comments. Residents were able to identify their allocated key worker. One resident told the inspector that he would like to get out more and evidence was provided by the activities co-ordinator that the needs of this individual were being addressed and specific monthly outings arranged Another resident also said he is working towards getting his own flat in the community and wishes to get married to his girlfriend. He also said he would like to go on holiday with his girlfriend. The care plan documentation does make reference within the risk assessments of some limitations on this person’s freedom. However there were not any goal plans in place that supported the individual to work towards his aspirations of having private time and space to further develop his personal relationships and this should be discussed with relevant professionals. 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. 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 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. Bracken Villa Care Home DS0000008635.V340625.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): 11, 12, 13,15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to develop independent living skills and to take part in community activities and educational opportunities. Residents are happy with the meals provided and that they are involved with choosing and cooking the meals. EVIDENCE: It is the culture in Bracken Villa that the residents share responsibility for different household tasks. Thus, encouraging independent living skills. Two residents live in their own independent living flats and are working towards living independently. Some residents are under guardianship orders under the Mental Health Act and therefore restrictions are imposed regarding this and are documented. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 14 It was evident from discussion with both residents 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 residents also. Residents and staff have created a quiet garden area, which houses guinea pigs. A memorial garden is being developed in memory of a member of staff who died in April. Vegetables and salad items were also growing in the garden, which residents take responsibility for tending with staff support. In house entertainment systems were provided in the main lounge, such as a wide screen television, music centre, DVD and SKY television and a fish tank. 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. From information provided and discussion with residents, not all staff respect residents right to privacy. The manager has been informed of specific issues. On the day of the inspection staff were observed knocking before entering residents rooms and staff demonstrated how privacy and dignity is promoted. Residents were observed using keys to their rooms. Lockable facilities were available in the rooms. Residents informed the inspector of a recent trip to Bruges and that the minibus is currently out of use. 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’s viewed showed nutritious, varied and balanced meals. There is usually a monthly trip out to a local restaurant for a meal and themed activities/nights are arranged such as Caribbean and Chinese nights in which residents can sample varying foods from varying countries and cultures. Bracken Villa Care Home DS0000008635.V340625.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. 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. The healthcare needs of residents are mostly being met and there is good management of medicines in the home. Further development of healthcare plans and ‘communication’ follow-ups would enhance the resident’s quality of life further. EVIDENCE: Residents said they do not always felt listened to and discussions with staff showed that within the current systems, there was the potential for some communications to be lost or overlooked. Where staff communicates issues relating to residents, a follow up system would ensure that consistency of practice is maintained. Healthcare records indicated that routine health checks are supported, however there has been a lapse in annual well person checks and records for these need to be kept. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 16 It is also recommended that ‘Healthcare’ is included within the list of needs identified [Care, Social, Spiritual, External and Educational] and a care plan introduced for how the individuals healthcare checks are to be managed. One resident had recently seen the GP for some healthcare needs. Improved documentation and implementation of specific care plans, which detail how those needs will be monitored and evaluated would further improve the service delivery to residents. The home maintains good links and relationships with necessary resources such as Community Learning Disability Teams and community psychiatric nurses. The overall culture of the home is to promote choice, control and independence, however residents expressed some dissatisfaction in the surveys and on speaking with the inspector through the inspection process, that this is not always being promoted. The issues have been alerted to the manager. There is a policy in place for promoting sexuality and relationships, however care plans did not fully support residents in further developing their personal relationships or clearly provide staff with details of how to support private time for individuals within the boundaries of the individual placement. A brief assessment was made of the management of medicines in the home by inspecting the medication record charts of the people case tracked. There are excellent medication overview information on each resident taking medication, creating a medication profile and record of medication reviews and changes to medication. The management of medication is very well organised with three audit systems in place, which ensures any problems are detected early. There have been no reported medication errors. Bracken Villa Care Home DS0000008635.V340625.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. 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 complaints policy which resident’s are aware of, and know how to use. Policies and procedures for dealing with abuse are in place but these have not been followed in a satisfactory way, due to a lack of understanding of these. Training provision for the management team in this area will support resident’s safety. EVIDENCE: The registered manager had stated in the annual quality assurance assessment that there had not been any complaints logged with the home in the previous twelve month period however there were two formal complaints recorded in the complaints records in the home since the previous inspection, these were in relation to College placements and family contact issues. Both had been resolved satisfactorily. The residents spoken with are all fully aware of the complaints procedure and a copy is framed and displayed in resident’s bedrooms. However some relatives said they were not aware of how to make a complaint despite the information being provided. There is information in the relative’s surveys leaflets that inform relatives how to complain should they need to. It is recommended that reminder letters be sent to relatives in respect of this. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 18 The home now holds an up to date copy of the Nottinghamshire Committee for the Protection of Vulnerable Adults Policy and procedures for dealing with suspected abuse. The management of the home were advised at the previous inspection to speak with the Adult Protection Unit/Safeguarding Adults to ensure that they were aware of their responsibilities for referring safeguarding adult’s issues to the Lead Agency. However at this inspection there were three incidents recorded in the home that meet the criteria for referral under Safeguarding Adults, which had neither been notified under the Nottinghamshire Protocol or indeed notified to The Commission for Social Care under the requirements of Regulation 37. Seven other incidents including an incidence of restraint had not been notified to the Commission under the registered persons legal obligations to notify under Regulation 37. Protection of Vulnerable Adults training is provided for staff however a requirement is set for the registered manager and senior staff to attend training on No Secrets and Nottinghamshire agreed protocols For Protection Of Vulnerable Adults. A number of issues in respect of some staff conduct were raised throughout the inspection process. As a result of this the Commission For Social Care Inspection has referred the issues under the Safeguarding Adults Protocols for investigation. Staff spoken with was aware of the policy for whistle blowing and what action to take should they suspect or witness poor practice. There are also procedures for positive intervention to behaviours that challenge. Staff are trained in de-escalation techniques. Staff members spoken with said they had not been issued with a copy of The General Social Care’s Code of conduct booklet and this must be provided to all staff under section 62 of The Care Standards Act 2000 All service users have their own bank accounts. A sample of financial records were inspected at this visit and appeared satisfactory. Bracken Villa Care Home DS0000008635.V340625.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. 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. Bracken Villa is a clean and comfortable home, which provides adequate communal space and resident’s bedrooms are personalised. EVIDENCE: The property benefits from a large lounge and separate dining room. In addition, there is a well fitted and equipped 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. Bedrooms seen were very personalised with service users own furniture and chosen décor, including personal photos, artwork and posters etc. A ground floor bedroom now has an en-suite facility to meet the needs of the resident. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 20 From observation and being shown around the home, the premises were clean, hygienic and free from offensive odours. Disposable gloves were noted to be 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. Bracken Villa Care Home DS0000008635.V340625.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 showed adequate staffing on each shift. A staff member explained how staffing is not set in stone but is flexible around the varying needs of the service users living at Bracken Villa. An on call rota is also provided 24 hours for emergencies. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 22 The home follows the recruitment policy and procedures as defined by Millbury Voyage Limited, the organisation that Bracken Villa is part of. A sample of three personal files were examined and found to be satisfactory apart from a photograph and Identification required by regulation was missing on one new staff members file. It was discovered that the photograph had been sent to head office for use in the creation of an ID card. The home is reminded that all records required by regulation must be available for inspection at all times. 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. 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. The provision of training for staff in Sexuality and Relationships and Equality and Diversity is recommended. 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 and staff spoken with confirmed this. Bracken Villa Care Home DS0000008635.V340625.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service is run in the best interests of residents and their health and safety is promoted and protected. EVIDENCE: The manager is a registered nurse and has managed services for a number of years. The manager has completed the NVQ level 4. Residents and staff made positive comments about the manager. 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. Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 24 Various meetings take place, team leader meetings, staff briefings, staff meetings and night staff meetings. Milbury and Voyage Limited has its own quality assurance system. Resident 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. Action taken from the surveys should be recorded to demonstrate that residents are listened to and ideas acted upon. Regulation 26 visits and reports are provided monthly. Accident records are kept on individual service resident’s files. The records of Health and Safety servicing and checks were inspected to ensure that residents’ are properly protected. These were all up to date and well recorded. The staff have all completed their statutory training courses and they confirmed that their health and safety is promoted and protected by the provision of training and equipment. Bracken Villa Care Home DS0000008635.V340625.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 4 2 4 3 4 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 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 4 33 X 34 3 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 4 X 3 X X 4 X Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 26 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 YA23 Regulation 17 Timescale for action Ensure all incidents since the last 06/08/07 inspection are notified retrospectively to the Commission for Social Care Inspection and the three incidents, which also meet Safeguarding Criteria, are notified under Safeguarding Protocols and No Secrets Guidance. Ensure all future incidents are 06/08/07 notified under Regulation 37. All incidents, which fall within this Regulation, must be notified in writing to the Commission without delay to enable monitoring of the service provided to residents. The manager and senior staff 06/10/07 must attend training on the Safeguarding Adults procedures to ensure they know about their reporting responsibilities in terms of protecting residents. Ensure all staff is provided with a 06/08/07 copy of The General Social Care Councils Code Of Conduct. Requirement 2. YA23 17 3 YA23 13[6] 4 YA23 CSA section 62 Bracken Villa Care Home DS0000008635.V340625.R01.S.doc 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. 1. 2 Refer to Standard YA2 YA18 Good Practice Recommendations Further develop equality and diversity within the assessment documentation and in relation to staff training. Seek external support and guidance for residents who’s aspirations are to go on holiday with their girlfriends/and /or get married/ to support and further develop their relationships. Ensure appropriate documentation is in place for this in line with the homes policy on sexuality and relationships. Further develop the healthcare needs section within care plans, which detail; how residents healthcare is to be managed. Include annual well persons checks within this. Ensure staff files are always complete with information for inspection. Provide training for staff in Sexuality and Relationships and Equality and Diversity. 3 4 5 YA19 YA34 YA35 Bracken Villa Care Home DS0000008635.V340625.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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