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Inspection on 15/08/07 for Brackley Cottage Hospital

Also see our care home review for Brackley Cottage Hospital for more information

This inspection was carried out on 15th August 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is a relaxed and friendly atmosphere throughout Brackley Cottage Hospital and the staff go about their daily work in an unhurried and professional manner. Privacy and dignity is maintained at all times and all service users spoken with confirmed that they were well cared for and their care and support needs were met. Comprehensive care plans are in place for the long term service users, these give the reader a clear picture of the service users needs and the tasks to be completed to meet those needs. The registered manager is both supportive and approachable and families and friends are strongly encouraged to visit the service users. Appropriate procedures for the admission of new service users are in place and care plans and risk assessments completed for all service users are reviewed on a monthly basis. Staff working at Brackley Cottage Hospital have a good understanding of the service users individual care needs and all service users spoken with were most satisfied with the service they currently receive.A robust recruitment procedure is in place ensuring the ongoing protection of the service users in their care

What has improved since the last inspection?

All service users had either a needs assessment completed by the registered manager or for the intermediate service users, a referral which included their identified needs, in place. Care plans were in place for all service users and the necessary risk assessments had been completed. Care plans are now discussed with the service users and/or their relative and these are agreed and signed by the service user and/or their relative as being relevant. Generic care plans have been developed for the intermediate service users, which can be personalised for each individual. Consent has been obtained where bedrails are being used and bumpers have been purchased to reduce the risk of entrapment. All moving and handling assessments had been completed appropriately.

What the care home could do better:

Provide an environment that meets the National Minimum Standards. Attend to the decoration within the four bedded rooms, service users should be able to reside in well maintained rooms. Keep the door to the treatment room locked at all times. Safe and secure storage of medication and equipment will reduce the risks to both service users and their visitors. Include alternatives to the main meal on the menu. A choice of menu should be provided to the service users at all times Reintroduce formal supervision sessions and staff meetings, this will provide the staff with further opportunities for support and clear communication.

CARE HOMES FOR OLDER PEOPLE Brackley Cottage Hospital Pebble Lane Brackley Northants NN13 7DA Lead Inspector Diane Butler Unannounced Inspection 15th August 2007 09:45 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 Brackley Cottage Hospital DS0000012602.V341633.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. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brackley Cottage Hospital Address Pebble Lane Brackley Northants NN13 7DA 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) 01280 702388 01280 700329 Brackley Hospital Trust Claire Mansfield Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of service users must not exceed 14. The 14 service users will be in the category of OP No-one falling within the category of intermediate care may be admitted to the home when there are 9 persons in this category already accommodated within the home. No-one falling within the category of OP receiving nursing care and not intermediate care may be admitted to the home when there are 5 persons in this category already accommodated within the home. The beds located in the multi bed rooms must only be used for service users receiving intermediate care for rehabilitation, and must not be used for any other category, including palliative care. Service users whose anticipated stay exceeds 8 weeks may not be admitted into the intermediate beds. 26th February 2007 4. 5. 6. Date of last inspection Brief Description of the Service: Brackley Cottage Hospital is registered as a care home for older persons and provides nursing and intermediate care for up to fourteen service users. The home is situated in the market town of Brackley and is close to a bus route, a park and all the local amenities. Although there are no parking facilities within the grounds, parking is available along Pebble Lane where Brackley Cottage hospital is situated. There is a small garden to the rear of the property, which is accessible to the service users residing there and seats are available for service users and visitors to use. The accommodation, which comprises of two four bedded rooms, one double room and four single rooms, is located on the ground floor. A number of the rooms are served by a nurse call system, those that are not, have a hand bell for use when assistance is needed. There are two assisted bathrooms within the home and a small communal lounge, which the service users can use. Although Brackley Cottage Hospital is registered with the CSCI, the environment does not meet the National Minimum Standards. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 5 There is a Registered Nurse on duty at all times. Current fees as of 1st April 2007 are as follows: Single room £612.00 per week Double room £597.00 per week. Details of all charges, including what is not covered in the fee above, can be found in the nursing information pack which is given to all prospective and current service users. Also included in this pack is a copy of the Statement of Purpose (a document telling the reader about Brackley Cottage Hospital) a copy of the terms and conditions of stay and information on how to make a complaint should anyone wish to. Information on accessing the current CSCI (Commission for Social Care Inspection) inspection report is also included. Brackley Cottage Hospital also provides a 24 hour First Aid Unit which is open to the general public. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a five and a half hour period on Wednesday 15th August 2007. The registered manager and the general manager were on duty at the time of the inspection. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for service users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting four service users and tracking the care they received through looking at their records, speaking with them when possible and discussion with staff on duty at the time of the visit. A further four service users were spoken with during the site visit. Further planning for the site visit included checking the service history and last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. What the service does well: There is a relaxed and friendly atmosphere throughout Brackley Cottage Hospital and the staff go about their daily work in an unhurried and professional manner. Privacy and dignity is maintained at all times and all service users spoken with confirmed that they were well cared for and their care and support needs were met. Comprehensive care plans are in place for the long term service users, these give the reader a clear picture of the service users needs and the tasks to be completed to meet those needs. The registered manager is both supportive and approachable and families and friends are strongly encouraged to visit the service users. Appropriate procedures for the admission of new service users are in place and care plans and risk assessments completed for all service users are reviewed on a monthly basis. Staff working at Brackley Cottage Hospital have a good understanding of the service users individual care needs and all service users spoken with were most satisfied with the service they currently receive. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 7 A robust recruitment procedure is in place ensuring the ongoing protection of the service users in their care 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. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 8 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 Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 9 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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are appropriately assessed before moving into Brackley Cottage Hospital to ensure that their care and support needs can be met. EVIDENCE: A Statement of Purpose document is available to all prospective and current service users. Details included in this document, which has been reviewed since the last inspection in February this year, includes the aims and objectives of Brackley Cottage Hospital, details of the staff who work there and the qualifications they have gained and information regarding what services can be provided. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 10 The Registered Manager stated that no service user would be admitted into Brackley Cottage Hospital without first having their needs assessed. For service users moving into one of the five long term nursing places a visit is carried out prior to them moving in to ensure that their needs can be met. For service users who are admitted for intermediate care both a verbal and written referral is obtained from the person referring the service user. This ensures that the staff are able to provide the appropriate nursing care and support whilst they are rehabilitating. On checking the files belonging to the two most recent service users to move into long term nursing places it was noted that both had a needs assessment in place. A new needs assessment document has been developed since the last inspection, this includes looking at the prospective service users personal care needs, dietary preferences, mobility and whether there are any communication needs. On checking the files belonging to two of the service users currently receiving intermediate care, both had a written referral form in place, on checking these forms it was noted that these had been received prior to the service users moving in and included information as to why they were requiring intermediate care. The registered manager explained that she had very good links with the local hospital and GPs and would always contacted the person referring the service user in person, to ensure that she had all the relevant information to ensure that their needs could be met. Evidence of contact with the local hospital was seen in both of the service users files. Intermediate care is provided in two four bedded rooms. Due to the constraints that the building presents there are limited facilities or equipment to enable the staff to promote activities of daily living within the service users rehabilitation such as kitchen activities, however, service users are encouraged with walking and going up and down stairs and a Physiotherapist visits Brackley Cottage Hospital on a weekly basis to assist with their rehabilitation. An Occupational Therapist (OT) also visits as and when requested by the nursing staff, The Registered Manager explained that she meets with each service user and their relatives if possible to discuss what facilities they have at home, if concerns are raised that they may not manage when they return home, a meeting is called and the registered manager requests the OT to assess the service user. The OT will take the service user home for a visit and check if any Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 11 equipment is needed to enable them to manage with day to day activities. If equipment is needed, this is ordered and the service user is then allowed home. The registered manager writes a ‘discharge summary’ for each service user which is sent to their GP when they return home to ensure that they are aware of the service user return and their current health needs. Service users receiving intermediate care can stay at Brackley Cottage Hospital for up to eight weeks. Two of the service users spoken with were due to return home in the next week or so whilst a third service user was waiting to hear. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are looked after well in respect of their health and personal care. EVIDENCE: On checking the files belonging to the four service users case tracked it was noted that all included a care plan. The care plans belonging to the two service users who were receiving long term care were comprehensive in content and explained in detail what assistance was needed. Both of these care plans gave the reader a clear picture of the service users needs, why they needed the assistance they did, and what actions the staff needed to take to meet those needs. Both care plans were being reviewed on a monthly basis. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 13 The care plans belonging to the two service users receiving intermediate care were more generic in design, the registered manager explained that she felt that these were more user friendly for the staff, easier to use and could be personalised for each service user. These were not as comprehensive in content as the other two care plans checked. The registered manager must ensure that all actions to be carried out by the staff are included in these care plans. All files included a moving and handling risk assessment, a nutritional risk assessment and a pressure area assessment. Further risk assessments addressing the resident’s specific health and welfare needs were also included where applicable. Service users who require the use of bedrails have been appropriately assessed for their use, written consent for their use has been obtained by the service users or their representatives and all now have bumpers in place as required at the last inspection. On checking the daily records belonging to the service users case tracked it was evident that health care professionals were being involved in their care. These included the local GP’s, Community Nurse, Occupational Therapist and Physiotherapist. The registered manager also stated that the Podiatrist visits every six weeks. All service users spoken with stated that their current care needs were being met and that they were treated with respect and cared for in a dignified manner. Comments received included: “You couldn’t get the care anywhere else, we are spoilt”. “I need a hoist now and two people always accompany me, they are very kind”. “They care for you! I’ve not been disappointed”. “The staff are fantastic, kind and obliging”. A medication policy is in place, which includes actions to take should a medicine be given in error. Medication records were checked and were found to be in order, however, it was noted that on three occasions medication had not been signed for as given, this was for an inhaler which one of the intermediate service users is assisted with. The registered manager acknowledged this and stated that this would be dealt with immediately. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 14 During the visit it was noted that the door to the treatment room where the medication is stored was wedged open. The registered manager stated that this was because there was someone around during the day and so it was felt not necessary to keep the door locked during this time. There were no service users self medicating at the time of the visit. The registered manager explained that if any service users did wish to self medicate a risk assessment would be completed and the medication would be kept locked away. A 24 hour first aid facility is currently offered to the general public in conjunction with the local GP’s. This means that members of the public can call at Brackley Cottage Hospital if they have suffered a minor injury. Visits are normally made appointment and the nurse on duty will attend. Interaction between residents and staff was extremely positive on the day of the visit with staff members speaking to residents and visitors in a respectful, friendly and supportive manner. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visiting is encouraged to enable service users to maintain contact with family and friends. Provision of activities must be monitored to ensure that service users receive stimulation which suit their preferences and capacities. EVIDENCE: Brackley Cottage Hospital has very close links with the local community. Volunteers give there time on a daily basis to help with afternoon teas or simply to chat with the service users and a number of fundraising events have been held in the town on their behalf. Visiting is strongly encouraged and all service users spoken with stated that their relatives and visitors could visit at any time. One service user stated “There very good with visitors”. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 16 An activities list is in place and is displayed in the main office, this included reminescence sessions and bingo, though the registered manager stated that it was unlikely that bingo would go ahead. Board games, jigsaws and large print books are also available in the communal lounge. A communion service is provided every week. The registered manager explained that because of the restrictions the building imposes it was difficult to get the service users together, the inspector was also informed that it was very difficult to get service users to join in the activities offered so they have begun providing more one to one sessions with the service users having one to one chats etc with the staff. This currently suits the majority of service users residing at Brackley Cottage Hospital. These chats and any activities carried out are recorded in the service users daily records. When asked if they would like activities provided, one service user stated that they would join in if they were provided, another stated that they were more than happy chatting with the others in the room, whilst another stated that they were quite happy with things as they were. The registered manager needs to monitor this on a regular basis to ensure that the service users in her care receive stimulation through activities which suit their preferences and capacities. All service users spoken with stated that the food served was extremely good. The cook personally meets with all new service users to go through what they like and dislike and whether they are on any special diets. This information is then recorded and kept in the kitchen for reference. These records were seen during the visit. One service user stated, “The cook came to ask what I liked and didn’t like”. On checking the menu it was noted that a nutritious and balanced meal is provided every day and the meal seen during the visit was well presented, hot and appealing in appearance. It was noted that the menu did not record an alternative meal if someone didn’t like what was on offer. The cook stated that an alternative is always available, all service users are informed of whats for lunch etc each morning, if the service user doesn’t want it the cook will visit the service user and an alternative would be chosen. Comments received included: “The food is all fresh and local meat, its beautiful”. “The food is fantastic, well worth eating”. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 17 “I havent eaten so much in my life before”. There is no dining area available in Brackley Cottage Hospital therefore service users currently take their meals in their rooms. Service users are weighed on a monthly basis and have a nutritional assessment in their care plan to ensure that their dietary needs are met. Care plans include individual preferences in daily living including what time the service user prefers to get up, what time they prefer to retire to bed and what they like to do during the day. One service user stated, “We can get up when we want to and were usually bathed every other day. Weve got a bell so we ring that if we need anything, they were very quick this morning, they came straight the way”. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 18 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): 16,18, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to deal with complaints and to protect service users from potential harm. EVIDENCE: A complaints procedure is in place and all service users are informed of the procedure to follow on arrival at Brackley Cottage Hospital. All service users spoken with were aware of whom to talk to if they weren’t happy about something and all were confident that any concern would be appropriately dealt with. One service user stated, “I would talk to any of them, they would sort out any problem”. A second service user stated, “I’d talk to the nurse in charge”. The registered manager explained that no formal complaints had been received since the last inspection, this statement was supported on checking the information included in the AQAA document (Annual Quality Assurance Assessment) received prior to the visit. The registered manager is aware of the procedures to follow with regard to the protection of the service users in her care and staff members spoken with were aware of the actions to take should they suspect any form of abuse. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 19 The registered manager has completed training in the protection of vulnerable adults and the inspector was informed that it was the manager’s intention to provide this training to the rest of the staff. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 20 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): 19,20,23,24,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although Brackley Cottage Hospital is registered with the CSCI, the environment does not meet the National Minimum Standards. EVIDENCE: Brackley Cottage Hospital is as its name suggests, a former cottage hospital. The shared rooms used for intermediate care resemble hospital wards with four beds in each and only a small lounge area is provided for communal use. The shared room and the single rooms used by long term service users were personalised and the service users were able to bring in their own possessions, furniture etc. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 21 It was noted in the rooms containing four beds that these were in need of some redecoration as the paintwork on the walls was peeling. There are two assisted bathrooms and a number of toilets throughout the home. On checking the toilet used by one of the service users case tracked it was noted that a raised toilet seat and rail was in place as stated in their care plan. On the day of the visit Brackley Cottage Hospital was clean and tidy and service users spoken with were quite satisfied with the accommodation provided. There is a small garden to the rear of the home that service users can access and benches are available for service users and visitors to use. The current accommodation within Brackley Cottage Hospital does not meet the National Minimum Standards. Both the CSCI (Commission for Social Care Inspection) and the owners are aware of this and certain restrictions are currently in place, including only admitting one service user who needs assistance with hoisting in each shared room. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures for the recruitment of staff are in place to ensure residents are not put at risk. EVIDENCE: There were sufficient numbers of staff on duty on the day of the visit to meet the current needs of the service users. Service users spoken with felt that on the whole there were enough staff on duty to meet their individual needs and all staff members spoken with on this occasion felt that there were currently enough staff on duty to enable them to care properly for the service users without feeling rushed. One service user spoken with did state “Maybe they could do with a few more staff especially first thing in the morning and last thing at night” The registered manager explained that should the work load increase then she has the flexibility to provide more staff on each shift should she need to. All service users spoken with confirmed that their current care and support needs were being met and on speaking with three members of staff on duty Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 23 during the visit it was evident that they were aware of the individual needs of the four service users case tracked. Comments received included: “I’m treated very well”. “The staff that are on are wonderful”. “If you had to recuperate anywhere I would recommend this place”. Two staff files were checked during the visit, both included an application form, details of their terms and conditions of employment and two references. Both also included evidence to confirm that a CRB (Criminal Records Bureau) check and POVA 1st check (Protection of Vulnerable Adults) had been carried out prior to them commencing work. The registered manager explained that all new staff complete a period of induction and a staff handbook, which includes relevant policies and procedures, is given to all staff employed. This was confirmed on speaking with two members of staff. A number of training courses have been provided since the last inspection including: Moving and Handling training Infection Control training Resuscitation training Fire safety training Training in basic food hygiene is booked for the 4th and 11th October this year. The Statement of Purpose document and the AQAA document received prior to this visit stated that over 50 of the staff have completed an NVQ (National Vocational Qualification) level 2 or above, the registered manager confirmed this statement and both staff members spoken with during the visit had completed this qualification. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 24 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users are promoted and protected. EVIDENCE: The registered manager, who has been in post for approximately two years, is a registered nurse with a number of years experience and has recently completed her Certificate in Management Studies. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 25 Brackley Cottage hospital’s general manager has completed her NVQ Level 4 in Management and NVQ Level 5 in Operational Management. It was evident during the inspection that the service users benefit from the ethos and management that the registered manager and general manager provide and positive relationships between staff, service users and visitors were evident throughout the visit. Staff spoken with stated that they felt able to discuss any issues with the manager, they found her very approachable and her door was always open. On checking two staff files it was noted that one included details of a supervision session being carried out though this was from 2006. On talking with the registered manager it was acknowledged that although she meets regularly with the staff members this is more on an informal basis and it was her intention to formalise these meetings and record the outcomes. On speaking with two members of staff the inspector was informed that staff meetings had been held in the past though there hadn’t been one for a little while. The registered manager explained that although a meeting hadn’t been held, handovers are held on a daily basis and during this time any issues are brought up and addressed there and then. The general manager explained that quality assurance questionnaires are issued to all service users on a six monthly basis. This enables her to gain the views of the service users as to whether they feel they are receiving a satisfactory service. A completed questionnaire was seen in the file belonging to one of the long term service users and a service user spoken with also confirmed that they had completed a questionnaire. The inspector was informed, “someone came with a questionnaire to fill in”. Regulation 26 visits are also carried out by the general manager enabling her to assess the service being provided and to gather service users views. Staff have received training in fire safety, moving and handling, basic food hygiene and infection control and health and safety training is provided during the staff members induction period. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 X 3 X X 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 1 X X 1 1 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23(2)(d) Requirement The registered person shall having regard to the number and needs of the service users ensure that (d) all parts of the home are kept clean and reasonably decorated. Timescale for action 17/09/07 2 OP19 23 The decoration in the four bedded rooms must be attended to. The registered person shall 17/08/07 having regard to the number and needs of the service users ensure that (a) the physical design and lay out of the premises to be used as the care home meets the needs of the service users. The accommodation within the home must meet National Minimum Standards. This Requirement remains outstanding from previous inspections. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP12 OP15 OP36 Good Practice Recommendations The registered provider should ensure that the treatment room is kept locked at all times. The registered provider should ensure that activities are monitored regularly so that service users receive stimulation which suit their preferences and capacities. The registered provider should ensure that a record of meal choices is kept. The registered provider should ensure that all staff are provided with supervision. Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Brackley Cottage Hospital DS0000012602.V341633.R01.S.doc Version 5.2 Page 30 - 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. 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