Inspection on 21/06/07 for Bramble Lodge

This inspection was carried out on 21st June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bramble Lodge 17/11/05

Bramble Lodge 22/08/05

Bramble Lodge 10/02/05

Bramble Lodge 03/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Annesley Lodge Care Home

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

CARE HOMES FOR OLDER PEOPLE Bramble Lodge 82 High Lane West West Hallam Derbyshire DE7 6HQ Lead Inspector Angela Kennedy Key Unannounced Inspection 09:30 21st June 2007 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 Bramble Lodge DS0000019944.V327920.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. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramble Lodge Address 82 High Lane West West Hallam Derbyshire DE7 6HQ 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) (0115) 9444545 (0115) 9326566 Sue.Cland@ntlworld.com Bucintoro Limited Mrs Susan Kim Cumberland Care Home 40 Category(ies) of Dementia (16), Old age, not falling within any registration, with number other category (24) of places Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Plus Four (4) Day Care Places 16 places in the category of D (Dementia) Date of last inspection Brief Description of the Service: Bramble Lodge is a predominantly new purpose built Care Home providing 34 single and 4 double bedrooms for Older People. However as the service is registered for 40 people only two of the double bedrooms are used for double occupancy, the other two double bedrooms are used for single occupancy. The Home is set in its own extensive landscaped gardens that have been designed to enable wheelchair users and other resident’s easy access. Bramble Lodge is situated on the edge of a rural area and the village offers only a few shopping facilities. However, the home is only a short drive from the town of Ilkeston and the city of Derby, both of which offer good shopping facilities and amenities. The services offered are 24 hour staffed care, 3 meals per day, personal laundry, heating and lighting, transport a range of leisure activities and social events. At the time of this inspection visit the weekly and any additional fees were: £364 for occupancy within a shared bedroom and £406 for occupancy within a single bedroom. General toiletries were supplied by the home and included in the above fees. Items that were not included in the above fees were: Chiropody at £5.50 per visit Hairdresser range from £5 to £20 Dry Cleaning if required, the fees for this were dependent on the garments and number of garments to be cleaned. Specific toiletries again variable as dependent on products required. Information regarding the services and care provided to people living at Bramble Lodge is available within the homes statement of purpose and by contacting the registered manager at Bramble Lodge. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 5 Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over approximately 7 hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with residents and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete An Annual Quality Assurance Assessment and the information provided within this assessment has also been used to inform this inspection report. The registered manager was present at the inspection. Some of the staff team were spoken with to ascertain their views of the service and their opinion of the training and support provided to them. Four residents were case tracked and three of these residents were spoken with. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at plans and other documents relating to that persons care, talking to staff regarding the care they provide, talking to the resident if they are able to communicate or observing the care they receive. What the service does well: A high standard of care and support continues to be provided to the residents at Bramble Lodge. A wide and varied range of leisure activities and social events continue to be provided that meet with resident’s needs and preferences. The environment is well furnished and attractively decorated to provide a homely environment for the residents. The communal areas are light warm and clean, there is wheelchair access to the garden area, which is attractively and safely maintained. The staff team show a commitment to developing standards of care and work well together. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 7 A high level of training is provided and this is reflected in the numbers of staff with a National Vocational Qualification (NVQ) and training in all health and safety practices and training specific to the needs of the resident group. The food provided is varied and nutritionally well balanced and the cook demonstrates an enthusiastic and creative approach in catering for all resident’s dietary needs. 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. Bramble Lodge DS0000019944.V327920.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 Bramble Lodge DS0000019944.V327920.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): 3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Admissions to Bramble Lodge only take place if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. EVIDENCE: Four residents were case tracked throughout this inspection visit. All four residents had records in place that demonstrated that a thorough assessment of their needs and the support they required was undertaken before they moved into Bramble Lodge. All four resident had assessments that had been undertaken by the service that addressed all areas of need regarding their personal, social and health care needs. This included any prescribed medication that they were taking and Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 10 if they were able to administer their medication independently or required staff to support them with this. Evidence was in place that demonstrated that residents were involved in the assessment process whenever possible. Evidence was also in place that demonstrated that six monthly reviews were also undertaken to ensure any changing needs could be identified and the appropriate action taken to ensure individual’s needs continued to be met. The assessments in place clearly indicated each person’s abilities as well as the areas in which they needed some support. This indicates that the staff at Bramble Lodge not only ensure they can meet each persons needs but ensure that each individual does not lose the abilities and skills that they have. Some of the residents case tracked were funded through the local authority and therefore assessments had also taken place by the individuals assigned care manager/ social worker. One of the residents who was case tracked had specific health care needs and an assessment had also been undertaken by healthcare professionals relating to the support and care they required regarding their health. Three of the residents that were case tracked were able to express their opinions of the service and care provided to them and all three were very positive regarding the choice they had made to live at Bramble Lodge. All of these residents confirmed that the staff team were able to support them and ensured their needs were met. One person discussed how they had initially come to Bramble Lodge on a short-term basis to enable their partner to have a break from supporting them. They said that they had been so impressed with the service and care they received that they decided to move in permanently. This service does not provide intermediate care and therefore Standard 6 is not applicable. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10,11 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Resident’s individual plans clearly record their personal and healthcare needs and detail how they will be delivered. Efficient management of medication practices are in place at Bramble Lodge and this ensures that resident’s welfare is maintained. EVIDENCE: The care plans and risk assessment for the four residents case tracked were looked at. Information gathered from the pre admission assessment had been used to develop the care plans. All of the care plans seen provided detailed information of the support each person required and how they would like that support to be given. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 12 Each resident was assigned a key worker who was responsible for ensuring care plans were up to date. Care plans addressed what each person was able to do for themselves and if some support or encouragement was required in order for them to maintain their independence. Action plans were in place that identified the areas of need addressed in the care plans. These action plans were detailed and looked at the daily routines of each person and identified areas within their day where they would require some support. The action plans stated how each person would like that support to be provided. Action plans also addressed each person’s preferences and choices regarding their daily routines. All of the care plans seen demonstrated that residents had been involved in the development of their care plans whenever possible and if individuals were not able to be involved due to mental health needs their family or representatives did so on their behalf. All of the care plans seen had been reviewed on a monthly basis to ensure any changing needs were identified and the required actions taken to ensure resident’s needs were met. All areas of risk were addressed and this included the actions that staff were to take to reduce identified risks and ensure each residents safety, welfare and health care needs were maintained. The health care needs of each person were recorded and this included any specific support or care that was required and again the resident’s preference on how this care was to be given. Records were maintained of any assessments or treatments undertaken by health care professionals along with any appointments that had been or were due to be undertaken. On the day of the inspection a community pharmacist was undertaking a medication audit at Bramble Lodge, looking at the medication practices in place. Discussions took place with the pharmacist who confirmed that safe working practices were in place regarding medication. The pharmacist confirmed that the communication between themselves and the staff team was very good, which ensured that the service maintained up to date working practices thereby enhancing the safety of the residents. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 13 The pharmacist also stated that the home is proactive in their approach to medication practices and always acts on any requests made regarding improvements to practice. Staff received medication training from a pharmaceutical company, although the manager has now achieved a medication trainer’s award and was therefore now qualified to train the staff team and provide refresher training as required. The three residents spoken with were very positive regarding the care and support they received and all stated that they had no concerns or complaints regarding their care. One resident case tracked discussed how the staff had enabled them to maintain their independence at all times, and confirmed that they was able to come and go as they pleased. (The assessments in place for this person demonstrated that they were able to go out independently.) All of the residents spoken with confirmed that the staff team were respectful towards them and always maintained their dignity when supporting them with any personal care needs. Information regarding the wishes of residents in the event of terminal illness and death were also recorded and included details on any spiritual or religious requirements, preferences regarding staying at Bramble Lodge or going to hospital and any specific arrangements regarding funeral and burial choice and specific wishes following death. All recorded information seen had been signed and dated by the individual resident. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents at Bramble Lodge are involved in meaningful activities of their own choice according to their interests and capability. The meals provided are well balanced and nutritional. Innovative methods are used to ensure meals are enjoyed by people with swallowing or chewing difficulties. EVIDENCE: Then manager had spoken with the staff team to ascertain which staff were interested in dementia care. This group of staff worked mainly with the residents with dementia. Dementia care at the home was considered to be a specialist area of care and good methods of support had been established to ensure people with dementia Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 15 were provided with the support they required to meet their social and recreational needs. Staff undertook observation of residents in one hour sessions, this was done at induction with each member of staff and annually. This provided staff with a clearer insight into the daily lives and type of contacts each person with dementia experienced, which then allowed staff a more pro active approach to the social activities and stimulation required to promote individual well being. Visual activities were provided for residents with dementia such as shape sorting and using musical instruments. Memory diaries were held for individuals to stimulate their memories; this information was gathered from each resident’s families and close friends. An activities room was provided at Bramble Lodge where a variety of activities were provided such as art and craftwork, musical instruments, flower arranging and baking. An activities co-ordinator was employed at Bramble lodge four days a week. However on the day of this inspection she was unavailable to speak with, as she was supporting some of the residents on a day trip out. It was confirmed by the manager that trips out were arranged each week for residents who wanted to participate. Events were also undertaken at Bramble Lodge and these were advertised on the display boards. A bar was also provided and it was stated by the manager that this was usually available at events and functions for residents and their visitors. All of the residents spoken with confirmed that there was a variety of activities and events that they were able to participate in. The grounds of Bramble Lodge contained a variety of plants and shrubs and the manager confirmed that one resident who had an interest in gardening helped to maintain the garden and plants. A church choir visited Bramble Lodge once a month and a priest and vicar also visited on a monthly basis to provide communion or worship for any resident’s who wished to participate. The manager confirmed that none of the people presently living at Bramble Lodge were of any other religious denomination, but stated that if this were the case a minister for their particular faith would be welcomed. A ladies based church group also visited the home periodically and a local Methodist church also invited the residents to any social events that were taking place. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 16 One resident visited their local church. Two visitors were spoken with and were complimentary about the care and support provided to their relatives. Both stated that there was always plenty of activities and events going on for people to join in with and both visitors confirmed how welcome they were always made to feel by the staff team The home has information about the advocacy services provided by Age Concern and Care Aware and at the time of this inspection, one resident was using the services of an independent advocate. Residents were able to bring their personal items and furniture with them and some bedrooms were seen which confirmed this. The meals provided were varied and menus ran over a 4-week rota. All of the residents spoken with were very complimentary about the quality and variety of meals provided. Cooked meals were provided at each meal and this included breakfast and the tea time meal. Alternative dishes were available at all meals. The cook was extremely enthusiastic and showed a genuine interest in providing nutritional and appealing meals for people requiring a soft diet. Food was liquidised, softened and enriched individually and then cooked in food moulds to enable the cook to provide soft foods that looked like a proper meal. This ensured that meals still maintained the required texture but provided a more valuing experience for the people eating them. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 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. 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. Residents and their visitors are confident that any concerns they have will be acted upon, and the procedures and practices in place for Safeguarding Adults enhances the protection of residents. EVIDENCE: The manager stated that Bramble Lodge had received no complaints in the last twelve months. The format that was used to record complaints was looked at, and demonstrated that all complaints were recorded to ensure that each complaint was responded to and the outcome of each complaint recorded appropriately. The complaints policy was looked at and although well detailed it did not state that all complaints would be responded to within twenty-eight days. However the manager did amend the complaints policy to this effect during this inspection visit, and agreed that this information would be amended within each resident’s service user guide. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 18 All of the residents spoken with confirmed that they would be able to express any concerns they had with the manager and felt these would be addressed promptly. Two visitors were also spoken with and both were aware of the complaints procedure at the home. Both people confirmed that although they did not have any complaints, they were confident that the manager would promptly address any issues raised. Residents meetings were also held on a regular basis and this provided residents with further opportunities to express their views and become more involved in the provision of the service and the day to day running of the home. One Safeguarding Adults investigation had been undertaken at Bramble Lodge, this investigation did not relate to any care or provision that had been provided at Bramble Lodge but rather in relation to care provided to a resident prior to living at Bramble Lodge. Evidence was in place that demonstrated that the manager of Bramble Lodge had acted in the best interests of this resident’s welfare and a full investigation had been undertaken by the lead authorities. All records regarding this investigation had been retained. All staff had received training in Safeguarding Adults, and Derbyshire Social Services who are the lead agency in Safeguarding Adults had provided this training. The Safeguarding Adults policy in place linked with the information contained in Derbyshire Social Service’s policy. This ensured the correct procedures were followed in any Safeguarding Adults referrals or investigations. Independent advocacy services are advertised within Bramble Lodge to ensure any resident who wishes to seek the advice or support of these services is able to do so. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A safe, well-maintained environment was provided for the residents at Bramble Lodge and good standards of hygiene were kept. EVIDENCE: A tour of the building was undertaken, this included communal areas, some bedrooms, the laundry area, the kitchen and the small kitchen that is provided for residents and their visitors and the garden area. All areas seen were well maintained and attractively decorated. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 20 Resident’s were able to bring their own furniture and possessions with them, which provided personalised accommodation that reflected individual’s personal taste. A small kitchen was available for use by residents and their visitors to make drinks. The main catering kitchen was seen and appeared to be maintained to a good standard. As stated in standards 12 to 15 an activities room was provided at Bramble Lodge where a variety of activities were provided such as art and craftwork, musical instruments, flower arranging and baking. There was a selection of communal areas for residents, which meant that the people living at Bramble Lodge had a choice of place to sit quietly, meet with their visitors or be actively engaged with other residents. All communal areas seen were well maintained, attractively decorated and provided good standards of hygiene. Two domestic staff were on duty from Monday to Friday and one member of staff was on duty at weekends to maintain the high standards noted. All of the staff team at Bramble Lodge had undertaken infection control training, this indicates that staff have the knowledge required to ensure any risk of infection at Bramble lodge was reduced. Residents spoken with confirmed that the standards of cleanliness and hygiene at Bramble Lodge were maintained to a high standard. The laundry was staffed seven days a week and housed the appropriate equipment to ensure resident’s laundry could be managed and the appropriate disinfection standards maintained. Resident’s spoken with were happy with the laundry service provided by the home. The grounds of Bramble Lodge contained a variety of plants and shrubs and the manager confirmed that one resident who had an interest in gardening helped to maintain the garden and plants. A seating area was provided for residents within the garden and the manager discussed how the path around the garden was safe for all residents to use as it returned upon itself, therefore ensuring that residents with confusion could safely walk around the gardens. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 21 A continuous redecoration programme was in place that demonstrated that the refurbishment of Bramble Lodge was ongoing to ensure the maintenance of the home was kept up to date. Bramble Lodge DS0000019944.V327920.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 excellent. This judgement has been made using available evidence including a visit to this service. The staff team are trained, skilled and in sufficient numbers to support the residents at Bramble Lodge and the recruitment practices in place ensure the residents are supported and protected. EVIDENCE: The rotas were looked at and demonstrated that six care staff were on shift in the morning along with two domestic staff, one laundry staff, one cook and one kitchen assistant. In the afternoons and early evening five care staff were on duty with one cook and at night three care staff were on duty. An activities coordinator worked at the home four days a week and a driver/handy person was also employed at Bramble Lodge. The manager worked Monday to Friday and the deputy manager supported the manager in managerial task for three days a week and was rostered on shift for two days a week. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 23 Additional staff were rostered on shift when activities were planned, such as the outing undertaken by some residents on the day of this inspection where three care staff, the activities coordinator and the driver were on duty to escort seven residents on their day out. Residents spoken with indicated that there were sufficient staff on duty to support them. All care staff except three had achieved a National Vocational Qualification (NVQ) in care at level 2 or higher. All senior staff had achieved NVQ at level3 and the manager confirmed that senior staff had the option of training to level 4 in NVQ if they wanted to. The deputy manager had achieved a management qualification. The registered manager at Bramble Lodge is a qualified NVQ assessor and has an agreement with the registered manager of another residential home that is also a qualified NVQ assessor. The two managers assess the staff of the home they don’t manage, to ensure there is no conflict of interest. The recruitment files of three staff was looked at and all had the required recruitment information in place. A training matrix was in place and demonstrated that all mandatory training was undertaken and up to date. Staff trained in medication administration received annual training updates. Dementia training was provided to all staff and this training was updated annually and included in staff induction. As stated in standards 12 to 15 the manager ascertains which staff have an interest in dementia care and these staff are rostered to work specifically with residents with dementia. Staff spoken with stated that the training provided was of a high standard and specific to the resident’s needs. It was agreed by these staff that a very proactive approach to training was used to support staff in managing the needs of each individual. This included looking at individual members of staff ‘s specific interest relating to residents care that could be further developed through training. Bramble Lodge DS0000019944.V327920.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): 31,33,35,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration systems in place are based on openness and respect and an effective quality assurance system has been developed by a qualified and competent manager. EVIDENCE: The registered manager has achieved the Registered Managers Award and has numerous qualifications relating to health and social care, dementia, and assessing and teaching. The registered manager was also qualified to teach manual handling and medication training to the staff team. Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 25 Staff spoken with were very complimentary regarding the Manager’s leadership skills and felt she was easy to talk to and provided an open door policy for staff. Questionnaires were sent out to residents twice a year and the questions asked were linked to the national minimum standards, which indicates the home endeavours to ensure they meet the national minimum standards for it’s residents. The results of the questionnaires were then fed back to residents in a written summary. The results were also displayed on the notice board in a written summary, pye chart and graph. Residents meetings were held monthly in the mornings and followed by senior staff meetings in the afternoon, this enable feedback to staff from residents meetings and an opportunity look at any actions required from the discussions held at the residents meetings. Minutes of residents meetings were given out to residents and copy was also placed on the notice board. Newsletters were sent out four times a year to residents their family and the staff team. Audits were also undertaken of resident’s care plans, staff files, medication sheets, kitchen records, and personal files. This again demonstrates the homes proactive approach in ensuring records are maintained and up to date. Resident’s financial transaction records and monies were audited each month. The financial transaction records of the four residents who were case tracked were looked at against the money held for these resident’s and all monies held corresponded with the records kept. All transactions undertaken had two signatures to ensure each resident’s financial interests were safeguarded. Information regarding the use of all substances that were hazardous to health, such as cleaning products was recorded and all products were safely stored. Records of weekly fire tests were in place as was the electrical lighting check records and service certificates for equipment . All staff had up to date training in first aid, infection control and food hygiene. Bramble Lodge DS0000019944.V327920.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 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Bramble Lodge DS0000019944.V327920.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!