Inspection on 19/09/07 for Braemar House

This inspection was carried out on 19th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Braemar House 31/05/06

Braemar House 28/10/05

Braemar House 07/07/05

Braemar House 05/10/04

Braemar House 29/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Braemar House 38 Seaway Road Preston Paignton Devon TQ3 2NZ Lead Inspector Michelle Finniear Unannounced Inspection 19th & 20 September 2007 09:30a th Braemar House DS0000058135.V344626.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 Braemar House DS0000058135.V344626.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. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Braemar House Address 38 Seaway Road Preston Paignton Devon TQ3 2NZ 01803 666011 01803 666011 braemarhouse@btinternet.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Rian Marie Hill Miss Cara Marie Hill, Mrs Anna Teresa Hill Miss Rian Marie Hill Care Home 12 Category(ies) of Dementia - over 65 years of age (2), Learning registration, with number disability (12), Learning disability over 65 years of places of age (12) Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home be allowed to accommodate up to two service users named elsewhere with DE(E) 31st May 2006 Date of last inspection Brief Description of the Service: Braemar House is a large semi-detached property situated on the level, near the beach and all local facilities, whilst being within easy walking distance of the local Community Resource Centre. The home provides accommodation for up to 12 adults with learning difficulties two of who may have a Dementia associated with their learning disability. The home is situated in a residential area of Preston and service users are encouraged and supported to be an integral part of the local community. Fees range from £306.58 to £639.94 per week. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is about Braemar house and what has happened there since the last inspection visit in May 2006. For this inspection two visits were made to the home, one in the day and one in the evening to meet the people who live there who were out at work or college in the daytime. We also looked at all the information we have been sent about the home since the last time we went and sent letters to people living there and to the staff so that they could tell us privately what they thought about the home. When we went we looked around the home, talked to the people who live there and shared a meal with them. We looked at the records and plans the home keeps, and on how they employ and train the staff. What the service does well: People said Braemar House is a nice place to live. It is close to the shops and buses and the home has a car so people can get around. Peoples rooms are decorated as they wish, and some have their own bathrooms and toilets. There is a choice of rooms for everyone to use, but only a small garden. People who live there have known each other for a long time and get on well. The home is family run, with owners who work at the home daily. The owners have managed to find out lots of information about where people used to live. This information helps staff and carers to understand some of the life experiences that this person has had. The home asks people what it is like to live there, so that they know what is working well and what could be improved. A staff member wrote “They look after the clients to the highest quality making sure they come first”. People spoken to on the visits said they liked living at the home and had lots of friends there. Braemar House DS0000058135.V344626.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. Braemar House DS0000058135.V344626.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 Braemar House DS0000058135.V344626.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good. Good information is available about the home to help people decide if it is the right place for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Braemar House’s statement of purpose and service user guide gives people thinking about moving into the home full details of the services the home provides, so they can make a decision about whether the home is the right place for them. The service user guide is written in plain language and is currently being looked at by a local advocacy group to make sure that it is as easy to understand as possible for people with learning disabilities. The guide also contains copies of the homes statement of terms and conditions or contract. This is an excellent document, personalised with photographs and symbols. It is understood that people living at the home have had this document explained fully to them, and they had signed it to confirm they agreed with the contents. This helps to ensure that all the information provided is understood and is true. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 9 Files for three people were seen on the first site visit, and no new people have been admitted since that time. These had been selected to ensure a range of needs could be seen. Information was split into two files, a current person centred file, and a file for admission information and assessments, historical information and financial records. This ensures that current information on people is easy to find. Person centred plans are written using the persons input as the starting point. This helps to ensure that care is delivered in the way that they would wish, and that they are able to make their own lifestyle choices with support. Discussion was held with the owners on what they would do if a new person was thinking about moving into the home. At the time of the visit someone was due to visit to look at the home to see if it would suit them for a short stay. The owners could explain what they were going to do to make sure the person would fit in and that they could meet their needs. This included meeting the person, and having them visits the home to see what it was like. They would then meet the people who live at the home, and could come and have a trial stay before they made a decision. People who live in the home would be asked whether they wanted this person to come and live with them, and this is good practice as it shows that people are consulted about the way the home runs and that their views are important to the management. People who live at the home for completed questionnaires indicated that they had not received sufficient information about the home before they moved in, however this may be due to the fact that their placement was many years ago under previous management and legislation. One person who completed a questionnaire wrote “I came and stayed and decided I liked it.” Another said they “Had tea at Braemar” which had helped them decide to move in. Braemar House DS0000058135.V344626.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 9 Quality in this outcome area is Good. People living at Braemar House are supported to make choices in their lives and have full plans to show the support they need to live their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the first site visit, three peoples files were selected to be seen. These files were chosen to reflect a range of need. They plans seen were comprehensive, and had been drawn up with the support of the person they were written about, which helps to make sure that the plans show what is important to that person and how they wish their care to be given. Discussion was then held with the management, who were also the staff on duty, on one persons care plan and how this was reflected in the actual care that they received. They could explain clearly the care that this person needed, which was quite comprehensive in view of their physical problems. The plan referred to a number of additional assessments that have been Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 11 undertaken and advice that has been sought to make sure that the care given is the best possible care available. In addition to these files the home has been working extensively on developing person centred plans. These plans are extremely individual to each person, including pictures and references which are of significance to that person in a format they will understand. As an example, one plan involved a system of colour coding for places and people that the person had he enjoyed or not enjoyed throughout their life. Person centred plans helped the individual make sense of the plan, and where there are particular communication difficulties helped them to make staff understand what they want. For some people the use of this, along with life history work has been extremely significant in helping staff understand peoples life experiences and the challenges they face. Plans contain information on the management of risks, which is important in ensuring people lead lives that are not overly restrictive, and can take part in activities that contain an element of risk in an informed manner. Risk taking is important in ensuring the full development and potential of the person. People are encouraged to make lifestyle choices, which may include developing personal relationships and friendships, following chosen activities, hobbies and interests, visiting family, participating in household tasks and self care skills. These are detailed in their plans, and discussions with people living at the home confirmed these were things they enjoyed. Two people spoken to regularly go to church, and are supported in doing so. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12 13, 14, 15, 16, 17Quality in this outcome area is good. People have opportunities to lead full and active lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People at Braemar House have opportunities to live a full and active life, and are consulted upon aspects of the day-to-day operation of the home. Discussion was held with the management on how people spend their time, and it was clear that there are varied opportunities for people available within the local community. On the day of the first site visit most people were out at a work placement, at Dawlish Gardens project or the local resource centre at Hollicombe. Discussions with these people on the second visit indicated that they had been taking part in a variety of activity, particularly art and craft . Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 13 People were keen to show photographs of a recent holiday they had all been on, and it was clear from this that there was a great deal of contact and sense of community within the home. The owners family had gone on holiday with service users and photographs showed the whole group spending time together swimming and eating. People were also happy to talk about the celebration of birthdays and with the managers birthday within a few days were lanning how they would celebrate the event. The home has managed to access supporters bus passes so that people who need somebody with them when using local transport facilities can do so at minimal cost. The same applies to cinema tickets. Within the home there was considerable evidence of people enjoying and participating in hobbies and interests. During the first site visit one person was busy colouring and another knitting. Another was keen to discuss football and other activities they had been doing recently, with family or within the home. Within the home there is a fortnightly music group, which people are free to attend or not, and an exercise group which is soon to restart following the trainers maternity leave. People at the home could also discuss recent visits to pubs, specialist clubs such as Gateway and local restaurants. The home is situated close to the seafront at Preston and also close to local shops, takeaway is and transportation services. One person living in the home was keen to go into Paignton to buy some more wool the day after the visit, and staff agreed to walking into town with her. The home has an independent advocate who will act on service users behalf, and who is very well known to all the people living at the home. People are encouraged to continue and develop valued relationships ,with family, friends or advocates. Contact with family is enabled and people spoke of the pleasure they had from receiving telephone calls and visits from family members. Evidence of this could be seen in daily logs and in activity plans. People living at the home eat a balanced diet as far as possible. Packed lunches are generally taken out during the day, with the main meal being eaten in the evening. On the second site visit, the meal was shared with people living at the home. The meal prepared and served was a pasta carbonara bake, which was really enjoyed. Staff eat with people living in the home wherever possible, which helps to maintain a family atmosphere, as well as give people the opportunity to discuss their day and any concerns they may have in an informal way. People living at the home also spoke about how much they enjoyed a good fry up at the weekend and staff confirmed that this is generally split over two days, to provide a balance. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 14 Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21Quality in this outcome area is good. Some areas were excellent. Peoples healthcare needs are being met. End of life care was sensitively planned and delivered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three peoples files were seen and discussions held with the homes management about healthcare being provided. Discussion was also held with some of the people living at the home talking about their health and how their needs are met. Evidence was seen in peoples files of healthcare assessments such as breast screening and smear tests being available. Assessments could also be seen from visiting professionals such as physiotherapists, district nurses and speech therapy and regular visits from a podiatrist. Records are also kept of visits from General practitioners and the outcome of those visits. Peoples care is regularly reviewed to make sure that nothing is being missed. People spoken to confirmed that they were taken to the doctor if they didn’t feel well. One commented that the homes staff manage their hearing aids and support them with injections and blood testing to manage their diabetes. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 16 The homes systems for managing medication were also seen on the visit. The home has a medication policy and procedure and uses a monitored dosage system which means that medication is blister packed by the supplying pharmacist. This system reduces the risks of errors and makes it easier to check if medication has been given on a particular occasion. The medication cupboard was clean and all records seen were recorded appropriately. The home has a lockable refrigerator for medication such as unused insulin and eye drops. The homes storage and policy on administration is checked regularly by the supplying pharmacist. Controlled medication is being managed well with two staff signing for it’s administration and a stock balance held. Controlled medication requires extra security due to it’s strength or effects. The arrangements for palliative care for one person were excellent with staff having attended meetings of a local palliative care group and discussions held with district nurses and medical practitioners about anticipating future deterioration. Equipment is available quickly to ensure their changing needs or a sudden deterioration Oxygen therapy is being provided and managed, and the person has remained very much a part of the life of the home, keeping good contact with other people living there. Relatives views on the management of this end of life care have been sought and the person and their comfort remain at the heart of the process. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People are protected by the homes management of complaints and adult protection systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Braemar House has a clear complaints procedure. People living at the home who were spoken to said they knew who they would talk to if they were worried or unhappy about something and would be happy to do so. No complaints have been received about the service since the last inspection visit. The home has clear information available for staff on Adult protection procedures, which has been backed up by training, documentation for which was seen. One member of staff still needs this training but has been given in house instruction and seen a video. Adult protection training is important as it tells staff about what abuse is and what to do if they see or hear about something they know is wrong. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is good. Braemar House provides a comfortable and homely place to live and work in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Braemar House is situated in a residential area of Paignton very close to the sea front at Preston. Local shops, training centres and transport links are all within an easy walking distance. The home has parking but limited outdoor space for sitting or gardening. There is a large open plan lounge/diner, and a visitor’s room/computer room for service users. This means people have somewhere they can take relatives rather than have to sit in the communal lounge or their rooms. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 19 A tour was made of all areas of the home on the first site visit. This included peoples bedrooms, communal and service areas. All bedrooms are individual and attractive, showing evidence of their personal interests and tastes in colours and styles of furnishing. There are ten single bedrooms, many with ensuite facilities. One person confirmed their room had been recently decorated and that they had chosen the colours. Other people also said that their rooms were decorated in a way they liked, and one room recently done had been decorated while the person was away on holiday in order to minimise any disruption to their lives. People living at the home take a part in cleaning their own areas and keeping them tidy. One person who completed a questionnaire said a member of staff “ took down my flag and curtains to wash and helped me clean my room – I did the dusting personally. I clean my room and keep it tidy all the time”. The home has a suitable number of baths and a wheel-in shower facility on the ground floor. Risk assessments have been undertaken for water outlets, these are now all fitted with water temperature regulators where people would be bathing or showering. This is to ensure no one can suffer a scald as a result of coming into contact with hot water. The home has a specialist washing machine, capable of achieving a full sluicing cycle, which means that it is capable of ensuring total infection control of any contaminated linen or clothing. Appropriate arrangements are in place to dispose of clinical waste, which ensures service users are protected from any risks of odour or cross infection. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36. Quality in this outcome area is good. Staffing arrangements help to protect people living at the home and ensure they are cared for well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Braemar House has clear processes for the recruitment, selection and retention of staff, which offers a good protection for residents. Three staff files were selected at random for inspection on the first site visit, and anonymous questionnaires had previously been sent to staff members. Files contained all required information and demonstrated that all of the required checks, such as a criminal records bureau checks and references were taken up on appointment. These checks are important as they help to protect people from being cared for by staff who may be unsuitable to be working with vulnerable people. The home has procedures for equality and diversity monitoring in their employment, and Job descriptions are available for all levels of staff within the home. Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 21 Training records were also seen on the site visit, and discussion was held on providing a training matrix to ensure that it is clear what training is still needed and which needs updating.. The induction systems for new staff incorporate the sector skills standards for staff working with service users with a learning disability. This means that they are based on current best practice. Staff questionnaires confirmed they had received an induction on employment. Residents spoken to during the site visit interacted very well with both staff and management, and there are clearly very caring relationships that mean the home does operate like a family unit. Staffing levels seen were flexible to meet the changing daily needs of people living at the home and additional staff are on duty at times of greatest activity. This means people should not be disadvantaged and restricted from attendance at events or activities of their choice by the staffing levels. Some people are out of the building for much of the day, so evenings and mornings can be times of most activity and interaction with the highest staffing. Discussion was held on supervision systems and on ways to keep this still useful in a small home where staff work daily with members of the management team. Supervision is a system that combines professional development of staff and work place management. It should make sure that staff are working to their fll potential and in a consistent way to support people at the home. A staff member who completed a questionnaire said “I had great support from Cara and Rian –they both taught me all I know.” And another wrote “I cannot see anything that the service could do better, it is very well run by a competent management team” Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. The home is being well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Braemar house is a family run home, with the registered manager being Ms Rian Hill. Ms Hill has worked at the home for 12 years, and so has extensive experience of working with the service users. Rian Hill divides her day-to-day management responsibilities with her sister, Cara Hill, and mother Mrs Anna Hill also works at the home and is a registered owner. The home has a series of regular audits which look at such areas as cleanliness and management of medication. Questionnaires are sent to people living at the Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 23 home, their relatives and other stakeholders such as general practitioners and district nurses about the home. These are collated by the homes independent advocate and a person who lives at the home is involved in typing up the notes. Information from these and the internal audits are used to compile an annual development plan for the home, which acts as a quality assurance tool. This helps to ensure that peoples views on the home are listened to and to identify what is working well at the home and what can be improved. A sample of records were seen on the site visit including the homes fire log book and accident book and these both showed that records are being kept up to date. A review was held on health and safety issues at the home including the management of such issues as food hygiene, moving and handling and infection control all of which were satisfactory . These included policies and procedures, training for staff and appropriate equipment being provided, such as hoists and gloves/aprons. Gas safety certificates were provided and portable appliance testing for electrical safety was last carried out in April 2007. All staff have receive training in health and safety. Risk assessments are available for the environment, but are still needed for safe working practices. This helps to ensure that staff are safe doing their jobs. An example might be a pregnancy risk assessment to make sure that someone who is pregnant is not harming themselves or anyone else while at work. Braemar House DS0000058135.V344626.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 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 4 3 x 3 x x 3 x Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13 Requirement Risk assessments should be provided for safe working practices to make sure staff and people living at the home are protected and staff can work safely. Timescale for action 25/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Braemar House DS0000058135.V344626.R01.S.doc Version 5.2 Page 27 - 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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