Inspection on 04/05/06 for Braeside Care Home

This inspection was carried out on 4th May 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Braeside Care Home 05/02/09

Braeside Care Home 07/02/07

Braeside Care Home 10/01/06

Braeside Care Home 25/04/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Braeside Care Home 8 Royal Street Smallbridge Rochdale Lancashire OL16 2PU Lead Inspector Bernard Tracey Unannounced Inspection 4th May 2006 09:30 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 Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 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. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Braeside Care Home Address 8 Royal Street Smallbridge Rochdale Lancashire OL16 2PU 01706 526080 01706 860923 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) East & West Healthcare Limited Christine Julie Baines Care Home 36 Category(ies) of Dementia - over 65 years of age (13), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (22), Terminally ill over 65 years of age (2) Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 36 service-users to include: Up to 13 service-users in the category of DE (E) (Dementia over 65 years of age); Up to 22 service-users in the category of OP (Older People) Up to 2 service-users in the category of TI (E) (Terminally Ill over 65 years of age) Up to 1 named service user in the category of MD (E) (Mental disorder over 65 years of age) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The Registered Person must ensure that an assessment is undertaken of the manager and care staffs’ training needs in relation to caring for service users with dementia. Any ensuing training plan must be implemented and regularly reviewed. The service should at all times employ suitably qualified and experienced members of staff, in sufficient numbers to meet the assessed needs of the service user group, including at least 6 hours Registered Mental Nurse input each day. 10th January 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Braeside is a privately owned care home providing personal and social care, nursing and care for those with dementia. The home was formerly a domestic property, which has over the years, been extended to accommodate 36 residents. It is located on the main Halifax Road, approximately 1 mile from Rochdale and a regular bus service between Littleborough and Rochdale stops close to the home. Accommodation is provided on three floors in both single and double bedrooms. There is level access to the front door and a small garden/patio area is provided to the front of the home. There is no designated parking area but cars may be parked on the minor road. A copy of the most recent Commission for Social Care Inspection report is available in the reception area of the home. The home makes the following charges over and above the weekly care and accommodation fees that are listed after this section: Chiropody £10.00 Hairdressing £4.50 Men £6.00 - £19.00 Ladies Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 5 Fees charged by the home provided in April 2006 are as follows: Residential Care £326.00 per week General Nursing range of £350.00 per week Dementia Nursing range of £335 to £365.00per week The following Nursing Care Enhancements need to be added to the above figure: High Dependency £133.00 per week Medium Dependency £83.00 per week Low Dependency £40.00 per week The above Dependency Level is decided by a nurse not employed by the home but who works for the Health Authority Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The home was not made aware that this inspection was going to take place. Several weeks before the inspection questionnaires were sent out to doctors, social workers and district nurses, as well as to the residents of the home and their relatives. The questionnaires asked what people thought of the care and services provided by the home. The home was also asked to fill in a questionnaire. Two Inspectors spent 7 hours at the home. During this time they looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. How residents spent their time at the home, how they felt they were treated and the quality of the food was assessed. A full tour of the building was undertaken and time was spent looking at records regarding safety in the home. They also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. The Inspectors spent time speaking to 10 residents as well as speaking to 2 relatives, 6 staff, the nurse in charge and the manager. All of the key National Minimum Standards were looked at on this visit to the home. What the service does well: What has improved since the last inspection? Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 7 Most of the previous requirements and recommendations from the last inspection have been complied with. The care plans had improved. They gave a much clearer picture of how the health and social care needs of the residents were to be met. More work needs to be done however, to include in the plan what the residents are able to do, as well as what they are less able to do. Improvement was seen in the provision of activities at the home, both on a group and one to one basis. Staff have attended training and more is planned so that staff will be better able to provide care for the residents and develop themselves within their job. The staff and owner have worked very hard to improve the environment in the home and the owner says he is committed to continue to improve the standards in the home. The improvements have led to a more homely and comfortable setting. Six bedrooms have been totally refurbished. Two new TVs and DVDs had been purchased. All radiators were covered, and rooms lighter and brighter - new lighting had been fitted and dirty net curtains removed from some bedrooms. Where residents had wished to keep net curtains new ones had been provided. A number of new window units had been fitted in bedrooms. The uneven flooring between the two ground floor lounges had been levelled and resdeints said it was safer. Non-slip flooring in bathrooms and toilets had been cleaned but it had been ineffective. Maintenance of equipment and services have been completed on time. What they could do better: Ensure that residents are seen before coming to the home so that they are sure that their needs will be able to be met. The home must involve residents and relatives in drawing up and reviewing the care plans. Within this process the interests and wishes of residents regarding daily activities would be identified and a suitable activities programme must be developed for each individual. The care plans must include all of the residents’ health care needs and show how these are to be met. Continue to develop activities and improve recording of them. Continue refurbishment programme making sure necessary decoration and replacement of carpets is done. Send CSCI more detailed, prioritised renewal plan with projected dates. Ensure boiler is in full working order. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 8 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. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 9 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 Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 4 ( Standard 6 does not apply) The quality outcome in this area was considered adequate. This judgement has been made using available evidence including a visit to this service. Information provided to residents before admission has been reviewed to include all of the information required to make an informed choice of where to live. Not all residents had a detailed assessment undertaken prior to admission to the home therefore ensuring that all prospective residents had an assurance to residents, relatives and staff that the home could meet their needs. EVIDENCE: The new manager had reviewed and updated the Statement of Purpose and Service User Guide. Both documents were available on the notice board in the entrance area but updated copies had not been given to all residents. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 11 In most cases before any resident was admitted to the home an assessment of their needs was undertaken, either by a senior member of the nursing staff from the home or from the professional i.e. care manager requesting their admission. The assessment documents that had been completed of residents on the residential and nursing units were looked at. The assessments were detailed and gave a clear indication of the residents’ needs and their capabilities. The assessments looked at the physical, mental and social care needs of the residents but did not identify the involvement if any, of the resident or their relatives. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 The quality outcome in this area was considered adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan, but there is no evidence of involving residents or their relatives in the development and review of the plan. Evidence of updating information and changing actions appear in the care plans. Residents have access to health care services that meet their assessed needs both within the home and in the local community. EVIDENCE: Individual care plans were in place for each resident. The care plans of 4 residents were examined. The majority gave clear instructions and guidance on how the care needs of the residents were to be met when problems had been identified. The care plans included information about the residents’ routines in relation to their daily living. The care plans were reviewed monthly and any changes were noted and acted upon. One care plan, an emergency admission did not contain enough information for the care staff to adequately meet the resident’s needs. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 13 The manager informed the inspector that a review of the documentation in respect of the care plans had been undertaken. It was evident from examining care plans progress has been made with the documentation clearly stating the care needs of each resident. The resident or their relative had signed none of the care plans examined. A discussion with one relative identified that whilst she was kept continually informed about her relatives’ condition she had not been involved in the drawing up of the care plan. Residents and relative must be involved to ensure that important and relevant information is obtained, thereby ensuring an accurate and agreed care plan is in place. Risk assessments were in place and covered such areas as moving and handling, nutrition, pressure sores, the use of bed rails and falls. The residents were weighed at least on a monthly basis and the weight recorded on a chart kept in their care plan. A discussion with the residents identified that they had access to other health care professionals, such as dentists, opticians, chiropodists and district nurses. Evidence of these visits was kept in the residents’ individual files. The medications system was generally safe. Medications were securely stored; the prescription administration sheets were not always filled in accurately and there was an accurate record of medicines received into the home. Evidence was seen of hand transcribed medications being entered on the administration sheet had not been signed by two members of staff to avoid the possibility of errors being made. All members of staff receive instruction and training in preserving the privacy and dignity of service users on induction, and a signed form indicates acceptance that the training has been given and received during the induction process. Medical examination and personal treatment is provided in the privacy of the service users own room. Relatives and friends are encouraged to visit as often as possible and the home operates an open visiting policy, which is referred to in the Statement of Purpose and confirmed in discussion with service users relatives at the inspection. A discussion with the residents identified that they feel their privacy is respected and that they are treated with kindness. Residents returning comment cards further endorsed this and those interviewed who considered their privacy and dignity was respected at the home. Staff interviewed were able to describe good practice in this area. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. 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. Provision of social activities and integration into community life was based on residents past interests. Family and friends of residents were encouraged to visit and made to feel welcome. Residents were enabled to exercise choice and control over their lives. The dietary needs of the residents were well catered for with a balanced and varied selection of food. EVIDENCE: Improvement was seen in the provision of activities at the home, both on an individual and one to one basis. An activities co-ordinator provided half a days’ activities in each unit at the home and two care staff had been designated to plan and deliver activities on other weekdays. Discussion with residents indicated that care staff input had increased and activities provided were based on past and current interests The activities co-ordinator based on the residential/nursing unit described the research she had done into local community activities, which residents may enjoy. Following consultation with them she was arranging visits out. One planned visit was to a local museum where residents could re-learn knitting skills, and social interests recorded on care plans had been used to identify Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 15 residents who may enjoy the trip. Residents said staff were also trying to find a local pub that offered good wheelchair access for residents to watch the World Cup. On the day of inspection the carer and a relative took two residents out to a local beauty spot for the afternoon. Those remaining at the home were encouraged to sit outside in the sunshine, staff were seen to spend time chatting to them and ensured they were given cold drinks. Observation throughout the day showed that staff on both units spent time chatting with residents as they went about their work in the lounge, creating a comfortable and relaxed environment for residents to sit in. Those residents who chose to stay in their rooms did so, others enjoyed sitting in the lounge chatting, doing crosswords, watching TV and DVDs. Some who were less able were seen to sit dozing in chairs but were offered occasional stimulation from staff. The activities co-ordinator spoken with was aware of the importance of including everyone in activities, but particularly those who had few visitors. Visitors interviewed and completing Braeside questionnaires considered they were made welcome at the home and could see their relative in private. One relative commented on how impressed they were with ‘the welcome we receive’ and that the offer of a cup of tea was ‘much appreciated’. One visitor welcomed the opportunity to help with her relatives’ personal care and felt supported by staff in doing so. Drinks and sometimes food was provided for visitors. Religious services were not held at the home, although representatives of two faiths visited residents at the home regularly. Residents spoken with were happy with this provision. The choices residents made each day varied, dependent upon their mental frailty but residents generally chose what time to get up, go to bed, what clothes to wear, what to eat, where to spend their day, whether or not to participate in activities and whether or not they wished to have a key to their rooms. One resident who had recently moved into the home had chosen to take her dog and staff were supporting the resident in providing the necessary care. By choice, the majority of residents’ monies were managed by relatives, although two had chosen to mange their own. A resident/relative meeting had been held 3 weeks prior to this inspection and minutes showed that the manager had sought views on care provided and shared information about plans for the home. Questionnaires were also sent to everyone invited to the meeting and at the time of the inspection, ten had been returned. Menus were planned over a 4 week period and were seen to offer balanced, nutritious meals. Residents considered them to be a little repetitive, the cook Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 16 and manager were aware of this shortfall and plans were in place to review them after the cook had attended a course on nutrition and the needs of older people. The inspectors ate lunch at the home – a choice of sausages and onions or ham were offered along with fresh vegetables. Both meals were tasty and well cooked. A choice of dessert was also provided. Staff were seen to give appropriate assistance in a pleasant and encouraging manner. Some residents ate their meal in the dining room whilst others were served the meal in their own room or in the lounge area, dependent upon choice. Changes requested at the last inspection had been implemented and individual tastes were catered for. Inspection of food choice sheets kept at the home showed alternative meals were provided if residents did not want the menu choice. Suitable provision was made to meet individual dietary needs i.e. diabetic and soft diets. Hot and cold drinks were seen to be offered to residents on a regular basis throughout the time of the inspection. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. EVIDENCE: The home had a complaints procedure which was displayed on the notice board in the entrance area and included in the Service User Guide. Staff interviewed were familiar with the procedure. Residents and relatives knew who to speak to if they had a complaint but said that matters were usually dealt with straight away so there was no need to complain. These smaller issues were not recorded, the manager may wish to do so for monitoring purposes. The CSCI had received no complaints about the home since the last inspection. One complaint had been made to the manager during this time and was recorded in the complaints book. This was with regard to response to call bells. The matter was appropriately dealt with, within timescale. Residents spoken with, said response times to call bells was satisfactory. The policy and procedure used by the home for the Protection of Vulnerable Adults (POVA) was the Rochdale Inter-agency procedure. A whistle-blowing procedure was also in place and staff interviewed showed their understanding of it. The manager knew and understood the reporting procedure which she had appropriately used in the past. All staff had received POVA training and residents spoken with felt safe living at Braeside. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 18 Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building was safe, and whilst environmental provision had improved, it was in need of further upgrading. Hygiene practices were of a satisfactory standard. EVIDENCE: Observation and discussion with the manager, staff, residents and relatives clearly showed that improvement was ongoing at the home with regard to the premises. Residents and staff said that the manager had good taste and this was reflected in the total refurbishment of two bedrooms. Two new TVs and DVDs had been purchased. All radiators were covered, and rooms lighter and brighter - new lighting had been fitted and dirty net curtains removed from some bedrooms. Where residents had wished to keep net curtains new ones had been provided. A number of new window units had been fitted in bedrooms. The uneven flooring between the two ground floor lounges had been levelled and residents said it was safer. Non-slip flooring in bathrooms and toilets had been cleaned but it had been ineffective. The manager was Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 20 awaiting a visit from contractors to replace the flooring in 7 toilets/bathrooms this provision should be extended to all bathrooms and toilets. A decortaing programme was ongoing and 5 bedrooms were to be decorated shortly after the inspection. The garden area below the bus stop to the rear of the home had been tidied and the rubbish removed. This is an ongoing process and residents said the manager was endeavouring to keep on top of it. A handyman is employed and inspection of the maintenance book and checking of last 3 entries showed that each item had been addressed. He was also available on the premises throughout the inspection and replaced a faulty call bell lead as soon it was realised there was a problem with it. Other areas where improvement was needed was with regard to: cleaning/replacement of some bedroom carpets, replacement of the carpet between the dementia care unit lounge and dining room, and stairs leading up to it, and cleaning of the corridor carpet on 1st floor. Walls needed filling and decorating in ground floor shower where grab rails had been moved. Some bedrooms and the ground floor lounge were in need of decoration. Residents no longer used the lounge area on the 1st floor of the home. The manager may wish to tidy this room and promote its use as a quiet lounge for visitors and meetings. Suffiicent and suitable aids and adpatations were provided throughout the building to meet residents needs, assisted baths as well as a level access shower were provided. Bedrooms were personalised and a number of rooms had ensuite toilets. Resdients were able to bring small items of furniture with them. All rooms were let as single, some were large and could be used as bedsits. There was a choice of sitting areas in the home. GM Fire Officers and Environmental Health Officers had not visited since the last inspection. A laundry assistant was employed and the laundry had sufficient equipment, was clean and tidy. An orderly system was in place for returning clothes to bedrooms. The home was clean and all people spoken with said it was kept clean. A relative returning a Braeside questionnaire said they were always impressed by the cleanliness’. An odour was noted in two bedrooms - the manager said she would request domestics to shampoo the carpets, a new machine had just been purchased as the old one had broken. Observation and discussion with staff and residents confirmed there were satisfactory infection control practices at the home. Colour coded disposable aprons and gloves were used and sufficient stocks were held at the home. Staff spoken with were clear as to good infection control practice and had all attended appropriate training. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 21 Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Sufficient staff were provided to meet residents’ needs. Training has been increased for all staff but some remained in need of further input, including NVQ, in order to fully equip them to do their jobs competently. EVIDENCE: Examination of the duty rotas and a discussion with staff and residents showed that there was enough staff on duty to meet the care needs of the residents. On the nursing units 24-hour nursing care continues to be provided by qualified nurses. Suitably trained care assistants support them. Senior care assistants who have achieved their NVQ Level 3 in Care, manage the residential unit and suitably trained care assistants support them. The overall management of both units remains the responsibility of the Registered Nurse Manager. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 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 home was well managed and run in the best interests of residents by a manager who demonstrated a clear sense of direction and leadership. The home had limited quality assurance systems for seeking the views of residents and their relatives which affected their ability to plan the service in the best interests of residents. Residents’ finances were efficiently managed. EVIDENCE: Feedback from residents, relatives and staff was positive with regard to improvements at the home since the present manager took up post. Resident and relative meetings are held on a regular basis and minutes are circulated to people living in the home. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 24 opinions. Residents and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Staff supervision files show that individuals receive formal supervision with their manager on a regular basis and staff appraisals are also completed each year. The responsible individual completes a monthly Regulation 26 report, and sends a copy to the Commission. Records required for the protection of residents and the running of the business are in place, reviewed and up dated as required. Residents are aware that they can access their personal records as and when they wish to do so. With regard to maintenance of equipment, all were inspected by external companies within required timescale. One requirement was not fully met in that a Dorgard had not been fitted to room 4 - this was due to a misunderstanding by the manager. Fire drills were not held for staff at the home. Inspection of water temperature records showed improvement since the end of January when the fan on the boiler had been repaired. All temperatures were within a safe, acceptable range. The home has two boilers abd staff said that second boiler switched itself off at times. It was agreed that if this fault could be rectifed then there would be no need to replace the boilers. Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 25 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 X 3 Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 26 YES 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 OP3 Regulation 14 Requirement The manager must ensure that no resident is admitted to the home unless a thorough assessment has been made. All residents must have a care plan that sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health personal and social care needs of the individual are met. All care plans must be drawn up with the involvement of the resident and their representative Timescale for action 30/06/06 2. OP7 15 30/06/06 3. OP7 15 30/06/06 4. OP19 23 5. 6. OP28 OP33 18 24 A more detailed maintenance 30/06/06 and renewal plan must be sent to CSCI to address each of the areas highlighted in the report and to clearly identify priorities and timescales for these and planned improvements. A minimum of 50 care staff are 20/09/06 trained to at least NVQ Level 2 The provider must ensure there is an effective quality assurance and quality monitoring system based on seeking the views of DS0000063307.V289323.R01.S.doc Version 5.1 Page 27 Braeside Care Home 7. OP9 17 service users. (Previous timescale of 31/03/06 not met) An accurate record of medicines administered to residents must be maintained. 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The manager should ensure that all staff responsible for activities in the home make daily recordings of resident participation in activities. Staff should continue to develop activity provision throughout the home. Staff should ensure residents are regularly encouraged to exercise in the home. Hand transcribed medication should be witnessed by two staff members to avoid errors. 2. 3. 4. OP12 OP8 OP9 Braeside Care Home DS0000063307.V289323.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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