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

This inspection was carried out on 7th July 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bracken Villa Care Home 06/07/07

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 7th July 2006 03:00 Bracken Villa Care Home DS0000008635.V302312.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.V302312.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.V302312.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 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.V302312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 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 £1,165-£2134. Residents are expected to pay for hairdressing, nail care, major outings and holidays etc in addition to this fee detail obtained from the provider at 5th June 2006 in the Pre Inspection Questionnaire. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was carried out on the afternoon/evening of 7th July 2006 for duration of 5 hours. The methodology used included a tour of the environment, speaking with a group of seven residents and two residents were spoken with individually. The manager and five 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 pre Inspection Questionnaire was also used to support the evidence gathered for this inspection. The inspection was very positive and it was clearly evident that the support given to residents 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 once again. What the service does well: Outcomes for residents at Bracken Villa remain positive and the home is well organised and managed to a high level. 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. The residents spoken with confirmed that they were 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 Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 6 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 conduct and management of the home, the day to day operations, ethos and quality monitoring are commendable. 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 DS0000008635.V302312.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 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 the following standard(s): 2,4 Quality in this outcome area is good. 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: Initial assessments were seen in the three development plans examined and the manager explained the process of assessment regarding a 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 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 Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 9 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. 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 is recommended. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 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 the following standard(s): 6,7,8,9, Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 DS0000008635.V302312.R01.S.doc Version 5.2 Page 11 All of the residents spoken with, including a recently admitted resident 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 CPNs [Community Psychiatric Nurses] as necessary. The development plans were presented methodically and are well structured. Key support staff presents an overview of resident progress for discussion in team meetings on a three monthly basis, 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 but understood that this is being discussed with the management of the home and his social worker as part of his personal development and within the structure of being able to live in this type of group home. The service user also said he is working towards getting his own flat in the community. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 12 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 dayto - day running of the home. One resident had recently moved out of the home, on to a more independent living situation, which vacated one of the semi -independent bungalows for another resident to be able to move into. The resident was delighted to have this opportunity and reported that he continued to be very happy and that the service provided at the home is excellent. Residents reported that they check their fridge temperatures regularly etc. 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. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,16,17 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 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. 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. A resident explained to the inspector how they take the temperature of the fridge and kept their flat clean and tidy. The flats were not inspected at this visit. 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. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 14 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 and staff have created a quiet garden area, which houses guinea pigs. Residents informed the inspector that the arrival of two ferrets was imminent. 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. This room now also doubles up as staff training room when needed and has been equipped for this purpose. From observation and discussion with residents, 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 residents were seen engaging and interacting with each other. Residents informed the inspector of forthcoming trips arranged to Bruges, Butlins at Skegness and to see the Golden Eagle in Cumbria. On the evening of the inspection one service user went out for a personal appointment and several to the pub supported by staff. Others enjoyed a relaxing evening in the garden. Residents confirmed that mail is given to them unopened. The residents’ preferred term of address is documented in the development plans. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 15 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 a communication board in the kitchen 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. A system has been introduced for stock rotation and use by dates. A sample check on use by dates was satisfactory. 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.V302312.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 at least once during a 12 month period. 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 available evidence including a visit to this service. 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 DS0000008635.V302312.R01.S.doc Version 5.2 Page 17 The system for documenting healthcare checks has been revised and information for healthcare checks was well documented and provides a good audit trail of health care. An assessment was made of the management of medicines in the home. Policies for medicines management are now kept in the office and copies of these are kept with the medication. The drug error policy is sited where staff can instantly access this, informs staff that any errors in medication procedures must be reported to CSCI under regulation 37 requirements. There was excellent medication overview information on each resident taking medication in the medicines cupboard which copies are also kept within the individual development plans in 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. Clear warning notices are visible both on cupboards and within the medication administration records for contraindications and adverse affects. Rectal diazepam is used in the home and this has been appropriately authorised and staff are trained by the PCT in its use. There were no controlled drugs or sharps used in the home at this time. The treatment room although small was kept well organised and clean and although there was no need for cool storage arrangements on the day of the inspection the home has accessed a mobile medicines fridge when needed and temperatures were said to have been monitored. The storage temperatures of the medicines were not however being taken, this should be re-instated and recorded. Staff training appears to be satisfactory and staff receive updates and certification for this from an external provider. A system has been set up so that residents can take responsibility for signing for their own medication with staff support. Bracken Villa Care Home DS0000008635.V302312.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 at least once during a 12 month period. 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 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. All complaints are responded to within 1 working day and concerns expressed are also recorded. Policies and procedures for dealing with abuse are in place but the manager needs to ensure that these are up to date. 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 two concerns reported since the last inspection but no formal complaints. The residents spoken with are all fully aware of the complaints procedure and a copy is framed and displayed in resident’s bedrooms. All information on the procedure is up to date and includes how to contact the Commission for Social Care Inspection. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 19 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/Safeguarding Adults regarding this] There are also procedures for positive intervention to behaviours that challenge. Staff are trained in de-escalation techniques. Protection of Vulnerable Adults training is booked for August but there has a waiting list as courses are oversubscribed. Discussion took place to ensure that senior staff and the manager were up to speed with the current Safeguarding adult’s protocols. Staff spoken with was aware of the policy for whistle blowing and what action to take should they suspect or witness poor practice. 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.V302312.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Quality in this outcome area is adequate. 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. Resident’s bedrooms are personalised. The toilet and bathroom provision is adequate but could be improved by further en-suite provision and refurbishment of the bathroom and toilet facilities. The patio needs attention to ensure it is safe. The resident’s independence is otherwise maximised by the facilities and equipment in the home. 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 residents 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 and vegetable plot, 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 Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 21 hoping to proceed with en-suite bathrooms for the bedrooms that this is possible for, which would further improve the promotion of privacy and dignity for individuals. A contractor attended the home on the day of the inspection to quote for this. The home has sufficient bathrooms and toilets. The two bathrooms in the main house are now looking very tired and need upgrading to meet the standard of the rest of the environment. The contractor was also quoting for this work on the day of the inspection. A bidet had been removed and remaining pipework that was potruding from he floor had been capped and made as safe as possible, however these still presented a trip hazard and therfore must be resolved with priority. The floor covering to the floor covering in the brown bathroom, which was at risk of lifting and may cause a trip hazard at a previous inspection and secured at the last visit remained safe, however it has been secured temporarily with tape, which looked unsightly. The staff/visitors toilet has no wash basin, staff said they use the bathroom to wash their hands. It is recommended that whilst the bathroom/ensuite work is being completed that provision of a sink in the staff toilet is considered. 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. From observation and being shown around the home, the premises appeared clean, hygienic and free from offensive odours. New carpeting has been provided to the hallway and stairs in the last twelve months and work on radiator covers has been completed. 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. It was reported that one washing machine had been out of use for four months, which was causing some conflict between residents, as they undertake their laundry tasks individually and some residents were being inconvenienced by having to wait to use the washing machine, out of their routine and organised days. Food safety appeared well organised with aprons in use for food preparation and food probing and fridge temperatures recorded Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 22 A number of patio paving slabs had become loose and uneven. The manager reported that work to remedy this was being quoted for. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35, 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. Staffing hours at night should be reviewed. EVIDENCE: The rota appeared to show adequate staffing on each shift. The manager and 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. The manager reported that recruitment had been more difficult recently and that this was probably due to local competing services in the area. An on call rota is also provided 24 hours for emergencies. It was reported that Voyage had made changes to in relation to hours of work and contracts recently, which had meant that only one staff member is on duty at night sleeping in. This has resulted in a house rule being implemented [which residents have agreed to comply with] that residents are required to retire to their rooms by 10pm in the week and 11pm Friday and Saturday nights, to accommodate this. Although residents were complying with this arrangement, there was a general feeling that this arrangement was not conducive with the homes philosophy or age appropriate for the adults living at the home. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 24 The staffing minimum hours for the home should be based on at least 210 care hours between 7am and 10pm. As residents contribute to cooking, cleaning and laundry duties with staff support and additional 32 hours should be added to this = 242 care hours. One to one funding hours need to be calculated in addition to this and where dependency needs of residents. It is recommended that the arrangements for night staff be reviewed. The home follows the recruitment policy and procedures as defined by Voyage Limited, the organisation that Bracken Villa is part of. A sample of four personal files were examined and found to be satisfactory. Training records were also satisfactory[induction and LDAF included] 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. At a previous inspection residents had 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. It was reported by staff and residents at this inspection, that the situation had now been rectified completely. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 41,42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 completed the NVQ level 4. Residents and staff made positive comments about the manager, for example, staff said of the manager, he is approachable respected by both residents and staff, he has an individual style of management, he has a good sense of humour but can be firm when needed. Staff also added they enjoy their work. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 26 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. Various meetings take place, 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. A member of staff takes responsibility for quality monitoring and explained the process, including resident surveys and many audits. 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. The incident records were examined and regulation 37 notifications have been made to CSCI when relevant. All records are kept secure. Evidence of mandatory training provided on induction and as refreshers was seen Fire tests and drills are carried out generally as often as they should be. [Three gaps were noted, which was when the handyman was on leave] It is advised that holidays are indicated in the diary so that another staff member can ensure the fire test is completed in the handyman’s absence. Fire drills were recorded but not the names of the individuals taking part and this should be actioned. A fire safety risk assessment was available and examined. 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, these were reviewed regularly and were comprehensive. One member of staff takes responsibility for ensuring the correct data is kept on this topic. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 27 Water outlet testing records were satisfactory. The handyman reported that a check for leigionella prevention had been carried out and explained the required checks alongside the evidence of records. Portable appliance test records, gas safety, electrical certification, accident records were all satisfactory A health and safety committee including a resident representative operates. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 28 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 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 4 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 X 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 4 3 X 3 3 X Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 29 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 2 Standard YA24 YA27 Regulation 23 16,23 Requirement Ensure the paving slabs are levelled and secured on the patio Ensure the refurbishment of the communal bathrooms is carried out promptly Timescale for action 07/10/06 07/10/06 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 5 6 7 Refer to Standard YA2 YA20 YA23 YA24 YA27 YA27 YA30 Good Practice Recommendations Further develop equality and diversity within the assessment documentation and in relation to staff training. Ensure the storage temperatures are monitored and recorded Ensure the Safeguarding Adults protocols in the home are up to date. Consider the Provision of hand washing facilities in the staff toilet-consultation with the Environmental Health Officer is recommended. Make regular checks on the flooring in the brown bathroom regarding the potential trip hazard. Provide en-suites to bedrooms where space allows Ensure the second washing machine is repaired/replaced promptly DS0000008635.V302312.R01.S.doc Version 5.2 Page 30 Bracken Villa Care Home 8 9 YA33 YA42 Review the night staff hours in relation to the philosophy of the home. Delegate the responsibility of fire alarm testing in the absence of the handyman and record, which residents and staff participate in the fire drill. Bracken Villa Care Home DS0000008635.V302312.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Nottingham Area Office 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 DS0000008635.V302312.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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