Inspection on 09/01/07 for Brackenlea Care Home

This inspection was carried out on 9th January 2007.

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

The inspector 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

Brackenlea Care Home 07/09/07

Brackenlea Care Home 16/01/06

Brackenlea Care Home 23/08/05

Brackenlea Care Home 01/02/05

Brackenlea Care Home 27/07/04

Brackenlea Care Home 02/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Brackenlea Care Home Pearson Lane Shawford Winchester Hampshire SO21 2HE Lead Inspector Mrs Pat Trim Unannounced Inspection 9th January 2007 09:00 X10015.doc Version 1.40 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 Brackenlea Care Home DS0000057455.V323312.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 Older People. 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. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brackenlea Care Home Address Pearson Lane Shawford Winchester Hampshire SO21 2HE 023 80 363246 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) Shawford Healthcare Ltd Mrs Jacqueline Deborah Coles Care Home 25 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (25) of places Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Brackenlea is a care home providing personal care and accommodation for 25 older people including those who have dementia. The home is located in the village of Shawford three miles south of Winchester and is within walking distance of a mainline station, bus route and post office. All bedrooms are single; twelve of these have en-suite facilities. There is a lounge, a dining room and a conservatory. The home has an established garden and seating accessible to service users. The fees as given in the pre inspection questionnaire are between £405.00 and £440.00 per week. Items not covered by the fee include hairdressing, chiropody, toiletries, newspapers and magazines. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out by one inspector in 8 hours. The key standards were assessed by case tracking 3 residents and talking with 4 people currently living in the home. Time was also spent observing staff practice and talking with 2 care staff, the cook, the care services co-ordinator, the registered manager and a representative of the provider. Some time was spent reviewing a random selection of documentation and a partial tour of the premises was carried out. Prior to the visit a review of the home’s recent history was undertaken, including the previous reports. Information was also gathered from the preinspection questionnaire, which was completed by the home. The people living in the home had previously expressed their wish to be called residents. This term is therefore used throughout this report. What the service does well: The home presents a warm, lively environment with good interaction between residents and staff. Visitors to the home are made welcome and are seen as very much part of the resident’s support network. Efforts are made to involve residents in their care and in the daily routines of the home. They are encouraged to help write their care plans and to see they have support in the way they wish it. Comments included ‘they are very good here. If something is wrong, they sort things out.’ ‘If I wanted help I would get it’. Residents said they were able to say what they liked and did not like about the home at their meetings, which are held regularly. They are able to say what sort of activities and outings they want and whether they get the meals they like. Residents felt they were able to make choices about their daily living and liked the activities provided. Comments included ‘we get lots of activities. Someone is employed to provide some. It’s up to you if you join in.’ Staff are well trained and have the opportunity to develop their skills though national vocational qualifications (NVQ) and courses that meet the needs of residents. The extensive renovations are providing a safe environment that is decorated in a way the residents like and that meets their needs. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have sufficient information to enable them to make an informed choice about whether to move into the home. Detailed pre admission assessments ensure residents may be confident they will only be offered a place if their needs can be met. EVIDENCE: On the day of the inspection a prospective resident was spending the day at the home, to give her an opportunity to meet everyone and for an assessment of need to be completed. The resident was shown the home, a vacant room on the ground floor and introduced to a number of residents. She was also able to have lunch in the home. During the morning staff kept going to chat with her and see she was all right. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 9 After lunch a senior care staff spent time completing an assessment of need with her, constantly reassuring her and checking if the information was correct. Time was also spent with a relative, collecting further information. Arrangements were made for a trial period to begin the following week and the prospective resident was given a copy of the service user’s guide. The sensitive way in which she was supported through the day contributed to her parting comment that she ‘looked forward to seeing them all on Monday’. The files for four residents were seen. These contained sufficient information about the resident’s needs to enable a care plan to be completed. Three had been completed prior to admission but one was dated for the day the resident was admitted. The registered manager said she was sure the date was an error and that the resident had visited prior to admission. One resident had come from a hospital setting in another part of the country. A copy of their assessment had been obtained prior to admission. Another resident had been in a local hospital prior to admission, but had been able to visit the home before coming in, when an assessment of need had been completed. The registered manager said it was the policy of the home to encourage residents to visit the home prior to admission and the statement of purpose included this information. Residents said they remembered visiting the home. Where this was not possible, the registered manager said she or one of the senior carers would visit to carry out an assessment. Where referrals were made through the care management process the registered manager said copies of care management assessment were asked for. Copies of these were also seen on file. The assessment of need completed by the home identified areas of ability and need and any potential risks, such as the risk of falls. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 AND 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to receive personal care in the way they like it and can be confident their health care needs will be met. Robust systems and staff training ensure medication is managed safely. EVIDENCE: Residents said the staff were very good at meeting their needs, but at the same time enabling them to do what they could for themselves. Each resident had a day and night care plan that gave information about how they liked to receive their care and what help they needed. Four care plans were sampled. Each detailed what the resident could do for themselves as well as what assistance was required. Some of the residents needed prompting rather than physical help and care plans made clear what was required. For example, prompting someone to change their clothes regularly. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 11 Risk assessments identified potential risks and what action should be taken to minimise them. For example one resident’s assessment identified the risk of falls. The care plan and risk assessment required staff to make sure she had her walking frame with her at all times. The registered manager said residents were involved in planning their care and the four plans seen had been signed by the individual residents to evidence this. During the inspection one resident was observed reviewing her care plan with a member of staff. All care plans seen had been reviewed at least monthly, although some monitoring tools used to identify changes had not always been fully completed. Residents said they had access to a wide range of health care professionals. Visits to or from health care services were recorded in residents’ files and showed that they saw their doctor, district nurse and chiropodist when required. Two residents had recently been referred to the community psychiatric services for support with their mental health needs and a visit from the continence advisor requested for another resident. The home had a policy and procedure for the management of medication and the registered manager said that only staff who had completed a training course were permitted to assist with medication. She had completed the course and had also completed an assessor’s course. Ms. Coles said that she did not assess staff as competent before permitting them to assist with medication and it was recommended that she do so to ensure staff put their training into practice. The majority of medication was supplied in a monitored dosage system. The medication administration record and medication held for one resident was checked. The tablets remaining in the monitored dosage system tallied with the written record. Medication kept as a controlled drug was stored in accordance with the Royal Pharmaceutical guidelines. A record was kept of all medication received into the home and any returned to the pharmacist. The registered manager said that no current residents managed their own medication but there was a policy and procedure in place so that staff could support them to if they wished to do so. Residents who were interviewed said staff treated them with respect. The induction programme for new staff includes looking at core values and staff were clear they needed to treat residents in a way that upheld their dignity and respect. Staff were observed providing support in a calm and quiet way and giving care at the resident’s own pace. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 12 Residents said they were addressed as they wished and this preference was recorded. They had keys to their rooms and could lock them if they wished. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about all aspects of their daily living. The activities they are offered provide mental stimulation doing things they enjoy. The food provided offer a balanced diet with choices that residents like. EVIDENCE: Residents felt they were able to make choices about all aspects of their daily living. Some liked to spend the day in the communal lounge, whilst others preferred to spend time in their rooms. Residents were seen moving freely around the home. Residents who were interviewed said they chose when they got up, went to bed and where they had their meals. Some liked to have breakfast in their rooms, whilst others liked to come to the dining room. Residents said the home provided them with activities in the home, but they could choose whether to join in or not. They said the home employed an activities co-ordinator and provided activities including exercise therapy, art and craft and visiting entertainment. A minister visited every month to give communion to those who wish to take it. The pre inspection questionnaire listed a wide range of in house activities such as quizzes, parties, pat the dog Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 14 and coffee mornings. Trips out included visiting an ice cream parlour and various clubs. Residents said a hairdresser visited the home fortnightly. Visitors to the home said they were always made welcome and could visit at any time. Residents said they could see their visitors in the communal areas or in their rooms. Residents’ meetings are regularly held to discuss issues and to get feedback from residents. Residents said one was due to take place the week of the inspection. The registered manager said action was taken to address issues raised at residents’ meetings. For example, changes had been made to the menu, following the last meeting. Some residents said they continued to handle their own finances and paid for services such as chiropody and hairdressing themselves. Others said their families looked after their money and the registered manager held a small amount of money on their behalf to pay for sundry items. Information about advocacy services was displayed in the hallway so residents could contact them if they wished. Residents said the meals provided were usually very good. The home employed two cooks, one of whom was always on duty to provide the main meal of the day and to prepare the evening meal. Residents said they could have a choice of main meal. The cook said cakes and puddings were usually home made and a sugar free version could be supplied for residents who had diabetes. Currently, one resident was vegetarian and vegetarian alternatives to meals were provided. Residents said they were offered three meals a day and could have snacks and drinks at any time of the day or night. Meals could be taken in the communal dining room or in the resident’s own rooms and people were seen choosing both of these options. Lunchtime was unhurried and residents sitting at small tables of four spent time chatting over their meals. Staff provided assistance in a quiet and unobtrusive manner. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to enable them to make complaints and be confident they will be informed of the outcome of any investigation. The home has an adult protection procedure and staff have received training. However, the procedure must be followed when there is an allegation of abuse if residents are to be protected. EVIDENCE: Residents spoken with said they were aware of how to make a complaint and had a copy of the complaints procedure. The commission had received no complaints since the last inspection. The pre-inspection questionnaire recorded two complaints received by the provider. These had not been substantiated. The complaints log contained information about how these complaints had been handled by the provider. Both had been acknowledged, investigated and feedback given to the complainant and their family. However, one complaint related to an allegation of abuse made by a resident. In discussion with the registered manager and care services co-ordinator it was established this complaint had not been referred to adult services under the adult protection procedure, but had been investigated by the provider under the complaints procedure. The registered manager explained why this course of action had been decided upon, but it was clear the home’s adult protection procedure had not been followed and this could have put residents at risk. The registered manager acknowledged the incident should have been Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 16 referred and said any future allegations would be referred under the adult protection procedure. On they day following this inspection a second incident occurred. The adult protection procedure was followed and the incident referred to adult services. Because of this action, no requirement in relation to adult protection referrals was made, but compliance will continue to be monitored at future inspections. Records showed staff had attended adult protection training. However, the manager’s assistant and one senior member of staff were unable to demonstrate they had a clear understanding of the actions they would be required to take if an allegation of abuse was made to them when they were responsible for the day to day running of the home. They were unsure which agency had the lead role in adult protection issues. This was discussed with the registered manager and care services co-ordinator who agreed they would arrange training for all staff in working with the adult protection procedures. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in a comfortable, clean and safe environment that meets their needs and that they like. EVIDENCE: The home is being extensively renovated to a high standard and residents said how much they liked the new décor. Radiators have been covered, hot water outlets fitted with thermostatic valves and upstairs windows restricted to protect residents from accidental injury. The second floor has been converted into offices and a training room, which gives staff the space to attend in house training and have somewhere quiet to complete their induction and national vocational qualifications (NVQ). It also means meetings can be held without encroaching on the residents’ communal space. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 18 The conservatory, which is adjacent to the lounge/dining room, was not being used temporarily, as the radiators were not providing sufficient heating. Two residents did not like the fact they could not get access, as they liked to use it as a quiet room. The management of the home confirmed they were trying to resolve the problem short term by providing heaters but had a long-term objective to improve the conservatory as part of the renovation programme. Staff were observed dealing with dirty laundry appropriately. All used protective clothing and had disposable gloves. The laundry had an impermeable floor and easily washable surfaces. There was an industrial washing machine that had a programme for sluicing and disinfecting soiled linen. It had a sink for hand washing. The home had a policy and procedure for infection control and staff said they were expected to refer to it for guidance. Recent training had included a course on infection control. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by well-trained staff in sufficient numbers to meet their needs. The home has a robust employment procedure but this must be consistently applied to ensure residents are protected EVIDENCE: Residents spoken with felt there were sufficient staff on duty at all times to meet their needs and that calls for assistance were answered quickly. Staff were observed throughout the inspection spending time with residents, chatting or playing games with them. Staff also felt there was usually sufficient staff on duty. The registered manager said that three staff were on duty during the mornings, and a cook and two cleaners. Two/three care staff worked in the afternoons and two during the evenings. The evening staff were supported by a kitchen assistant/carer who helped with tea, then provided personal care till 8.30 p.m. Care was provided during the night by two waking staff. The registered manager worked in the home during the day from Monday to Friday. The manager’s assistant or senior carer managed the home at weekends. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 20 The home exceeds the standard of 50 staff with a national vocational qualification (NVQ) as 10 of the 18 staff have achieved this qualification. Staff said they felt supported by the provider to develop their skills and have the opportunity to progress to NVQ3. Three staff, recently employed in the home, were case tracked to assess the quality of the recruitment process. All had completed an application, attended an interview, provided two references and had a criminal records bureau (CRB) and protection of vulnerable adults (POVA) check prior to employment. However, there was no evidence that this information had been used to obtain further information about applicants to demonstrate their fitness. For example, the registered manager had not explored gaps in one applicant’s employment history, or the reason why someone had left a previous post. She had not discussed comments made on a reference with either the applicant or the previous employer or established whether an applicant from overseas had permission to work in this country. Two staff were interviewed. Both had been interviewed prior to their appointment and had been required to complete the above checks. Copies of a new induction programme were seen on staff files. This comprised six units and was based on the Skills For Care induction programme. The care services co-ordinator said that staff worked in the home for a minimum of three days as supernumery staff with a mentor at the start of their induction. Both staff interviewed confirmed they had been required to complete an induction programme. They said they felt supported by the management and had the opportunity to access a wide range of training. Recent training for them had included moving and handling updates, food hygiene and infection control. Senior staff who provided supervision to care staff had attended a supervisor’s course. The pre inspection questionnaire recorded that recent training had included safe handling of medication, managing aggression and infection control as well as basic courses such as moving and handling. Certificates were seen on staff files to support this evidence. Both staff interviewed said they had regular supervision. Senior staff provided supervision to care staff and the registered manager supervised senior staff. Copies of supervision notes were kept on individual files. Staff said supervision was used to identify any care issues and training needs. The registered manager said she also worked on the floor to observe staff practice and to use what she sees as supervision topics. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home is well managed, but adult protection and employment procedures need to be used more effectively if residents are to be protected. There are systems that enable residents to give feedback about the service they receive. There are systems to make sure health and safety issues are addressed and residents are protected. EVIDENCE: The registered manager has a national vocational qualification (NVQ) 4 and a registered manager’s award. She has extensive experience of working in a residential care setting. The registered manager said she spent part of her day working with residents, carrying out her management duties during the afternoon. Residents and staff said she was approachable and during the Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 22 inspection both residents and staff were seen coming to her office for help and advice. Residents said she was a good manager and they liked her. However, during this inspection it was established the registered manager was not effectively managing all aspects of her role. She had not referred a serious allegation of abuse to adult services and was not aware she should have done so. There was also evidence that the employment procedure was not being used effectively to ensure all possible checks were completed on staff before they started working in the home. Residents said they had regular meetings to enable them to bring issues to the management of the home. Recently they had requested menu changes and these had been implemented. Minutes of these meetings are given to every resident. Residents also have the opportunity to give feedback when their care plans are reviewed each month. They have a key worker who helps them to do this. There are regular management meetings to review progress towards the longterm plans for the home. The provider receives a monthly report from the registered manager. The care services co-ordinator completes random audits on all processes within the home and questionnaires are sent to residents twice a year to ask for feedback about the service they receive. The care services co-ordinator analyses their responses and writes a report but, at present, residents do not receive a copy of this. The registered manager said some residents managed their own finances, but some like the home to keep small sums of money on their behalf. Written records are kept of individual income and expenditure, together with receipts of any items purchased. The amount held in one account was checked against the record and was found to be correct. There was evidence these records are randomly audited as part of the quality audit completed by the care services co-ordinator. Staff records showed that staff receive training in all aspects of health and safety. The pre inspection questionnaire listed training this year in food hygiene, first aid and moving and handling. Staff confirmed they received initial training and regular refresher courses. The pre inspection questionnaire listed the dates of service contracts and inspections of equipment used in the home. A random selection of these were seen during the course of the inspection and evidenced that the health and safety of residents and staff are maintained. Hazardous substances were securely locked away. The accident book had been completed for all accidents and injuries to residents. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 23 Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13(6) Requirement All staff who are responsible at any time for the management of the home must have training in working with the adult protection procedures. This is to ensure they have sufficient knowledge about the action they are required to take if an allegation of abuse is reported to them. The registered manager must ensure that a full employment history is obtained from applicants and any gaps in it are explored to make sure they are fit to work with service users. The registered manager is further required to ensure any employees from overseas can demonstrate they have permission to work in this country. Timescale for action 14/03/07 2 OP29 19(1) 09/01/07 3 OP29 19(1) 09/01/07 Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations That the registered manager completes an assessment of staff before they are permitted to give out medication unsupervised, to assess their competency. A written record of this supervision should be kept. Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Brackenlea Care Home DS0000057455.V323312.R01.S.doc Version 5.2 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!