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Inspection on 17/04/07 for Bramble Lodge Care Home

Also see our care home review for Bramble Lodge Care Home for more information

This inspection was carried out on 17th April 2007.

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

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

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

What the care home does well

Bramble Lodge provides a clean, pleasant and well-maintained home for people to live. It provides the residents with a comfortable and homely environment, offering a good standard of care to the residents. Extremely positive comments were made by residents, relatives and staff about life within Bramble Lodge. One resident said, "There is mutual respect here, we are all treated equally and when you need prompting, these is done with dignity". Relatives said, "We turn up unannounced I really feel he/she is being looked after, the main thing is that they listen to us and we work together", "He/she is so well looked after, they promote his/her abilities and he/she has done absolutely marvellous since being here". The staff team are happy and are clear about their job roles. One staff member said, "I absolutely love my job, no days are the same and you have time to sit down with the residents and spend time with them". Staff were interacting really well with the resident sand there was a sense of there being a really warm, caring and friendly atmosphere.

What has improved since the last inspection?

A number of improvements have been made since the last inspection. There were requirements and recommendations made and most of these have been improved upon. This includes, improvement to the recruitment practice and staff have received protection of vulnerable adults training Improvements were observed within the care documentation in particular the evaluations of care and the clear information flow. Further development is needed which will enhance these records further.

What the care home could do better:

Whilst care records have been developed since the last inspection, these could be improved yet further. There is the need to ensure that the assessments and care plans contain more personal information about individual residents needs and that the risk assessments are again more detailed. The medication systems in the main are fine, however there is the need for some more attention to detail in terms of accurate recording of administered medication and to ensure that administration directions are accurate. Whilst it is evident that staff training takes place on an ongoing basis, the actual training records do not clearly show how up to date each individual staff are with their mandatory training and it is unclear if all staff have completed relevant resident specific training. Some improvement could be made to the dining experience of the residents, ensuring a more conducive environment, with appropriate equipment. Additional detail is needed within a small number of in-house health and safety records, such as water temperatures and fire drills.

CARE HOMES FOR OLDER PEOPLE Bramble Lodge Care Home Delemere Road Park End Middlesbrough TS3 7EB Lead Inspector Jackie Herring Key Unannounced Inspection 17th April 2007 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 Bramble Lodge Care Home DS0000061455.V335338.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 Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramble Lodge Care Home Address Delemere Road Park End Middlesbrough TS3 7EB 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) 01642 322802 01642 322803 Grant Williamson Mr Kenneth Walton Care Home 35 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (15) Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate three named individuals who are under 65 years of age. To accommodate three individuals who are over the age of 50 years. Date of last inspection 24th April 2006 Brief Description of the Service: Bramble Lodge is a two storey purpose built 35 bedded care home with nursing which operates two separate units for different categories of care. One unit is for older people with a mental disorder and the other unit is for older people with dementia. All 35 bedrooms are single rooms with ensuite facilities containing a toilet and wash hand basin and the rooms meet the required size. There are a number of bathrooms and showers as well as a variety of lounge areas. The home is set in its own grounds, with car parking. Bramble Lodge is located close to shops, public houses and transport. The weekly fees for Bramble Lodge is £350 - £450. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key unannounced inspection and was completed in one inspection day, nine inspection hours in total. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. Three of the residents were involved in individual discussions with the inspector to seek their views and a further four residents were involved in informal discussion. A small number of relatives were also spoken to, as were staff members, the home manager and regional manager. A number of records were looked at including resident’s assessments and plans of care, staff recruitment records, complaints and maintenance records along with the pre inspection questionnaire. Indirect observations also took place and a number of resident and relative surveys were completed. This was a positive inspection, in which the inspector was warmly welcomed by all. Feedback was well received and there was constructive discussion throughout. What the service does well: Bramble Lodge provides a clean, pleasant and well-maintained home for people to live. It provides the residents with a comfortable and homely environment, offering a good standard of care to the residents. Extremely positive comments were made by residents, relatives and staff about life within Bramble Lodge. One resident said, “There is mutual respect here, we are all treated equally and when you need prompting, these is done with dignity”. Relatives said, “We turn up unannounced I really feel he/she is being looked after, the main thing is that they listen to us and we work together”, “He/she is so well looked after, they promote his/her abilities and he/she has done absolutely marvellous since being here”. The staff team are happy and are clear about their job roles. One staff member said, “I absolutely love my job, no days are the same and you have time to sit down with the residents and spend time with them”. Staff were interacting really well with the resident sand there was a sense of there being a really warm, caring and friendly atmosphere. Bramble Lodge Care Home DS0000061455.V335338.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. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have their needs assessed prior to admission to ensure that their needs can be met. EVIDENCE: Three sets of resident’s records were looked at during the inspection all of which contained a copy of the pre admission assessment. It had previously been confirmed that it is usually the home manager who conduct the pre admission assessment or a key staff member. There was discussion in regard to the care management assessment, as they are not always made available to the home staff prior to the admission of new residents. The manager agreed that this would be an area they would look at to ensure as far as possible that they had obtained this information prior to a new resident being admitted. The resident’s who live are Bramble Lodge are in the main funded by the Primary Care Trust and the Local Authority, as such, their needs are assessed by key staff prior to arranging admission to the home and must meet the requirements for the care Bramble Lodge provides. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 9 Residents and relatives confirmed that they had the opportunity to visit and look around the home and that the welcome they received along with the information was very good. Family members said, “We came for a look around, and felt welcomed immediately, they carried out an assessment and let us know that they could meet his/her needs”. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although residents and relatives are happy with the care provided assessments, care plans and risk assessments need to contain more personal and detailed information to ensure needs are fully met. The system for managing medication is reasonably satisfactory, however some review is needed to ensure robustness. EVIDENCE: Three sets of resident’s records were looked at. The records included a recent resident who had been admitted, a resident who had been living in the home for over a year and a random sample for the third. The residents records showed clear information flow from assessment through to risk assessment followed by specific care plans and evaluation. This process demonstrated that resident’s needs were being assessed and care plans had been developed and were being evaluated on a regular basis. The evaluations of care were informative and well written. There was clear evidence that these had been developed further and improved following the last inspection. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 11 Whilst care needs were assessed, the records could be developed further, with more individualised information about the person, their lifestyle habits and preferences and more specific detail in terms of care needs. Examples of these were shared with the manager and regional manager during the inspection feedback and it was agreed that all of the records could be enhanced further. This was also the same for where particular risks had been assessed; there is the need to have more specific information and detail. This included for example, a risk assessment detailing, “aggression”, however it does not specify if this is verbal, physical, or any potential trigger factors. Details for GP, District Nurse, Optician and CPN visits were available within all of the files examined. Very good staff/resident interactions were observed during the inspection. Staff spoke knowledgably about the residents and demonstrated a clear understanding about their individual needs as well as their lifestyles and preference and family contacts. One staff member said, “Life for the residents here is all about their needs, you get to know what they want, you talk with the family and you find out when they can’t tell you”, “The most important thing is to keep the resident happy, to meet their needs and to look after them to the best of our ability”. A number or residents were spoken to and they believed they were well cared for, one resident said, “There is mutual respect here, we are all treated equally and when you need prompting, these is done with dignity”. Another resident said, “personal care is done with respect and dignity and the staff are very discreet when in the bathroom with me”. Relatives who were spoken to during the inspection spoke extremely highly about the care provided to their relative. They said, “We turn up unannounced I really feel he/she is being looked after, the main thing is that they listen to us and we work together”, “He/she is so well looked after, they promote his/her abilities and he/she has done absolutely marvellous since being here”. The medication systems were looked at during the inspection and the storage, recording and administration of medications was in the main good. It was identified that the temperature of the downstairs medication cupboard was not being recorded and this is needed, to ensure that it did not become too hot. Medication Administrator Records were looked at and there were occasional gaps with no corresponding reason. It was also identified that the directions for the administration of one medication was incorrect, immediate action was taken by the home staff to address this issue. There were also occasions when the records of administration did not correspond with the number of tablets in the blister packs. Storage and ordering of medication was fine and a staff member clearly outlined the procedure for ordering of medication and the returns. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Activities are in the main well managed for residents ensuring social, religious and recreational needs are provided for, these could be linked to a more detailed social and lifestyle assessment. Residents where possible are able to control aspects of their lives, their independence and make choices. Residents are generally provided with nutritious meals but not always within the most conducive of settings. EVIDENCE: Care staff said there was time to be involved in a range of activities with the residents and gave examples such as Bingo. There is one activity co-ordinator in post with another due to start in the near future. There is no actual programme of activity although it was confirmed by staff that equipment such as cards and arts/crafts are available. It was also confirmed that a minibus was available from time to time and outings would be arranged. Staff also said that residents were able to go out for walks and some regularly visited the local shops. One resident said, “ there are times when there was little to do and that it did make for a long day”. During the inspecting staff were observed sitting, chatting with residents. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 13 It remains unclear, as identified at the last inspection, how the resident’s social and lifestyle assessments are used to develop either individual or group activities. There was also some discussion about developing further knowledge in relation to effective dementia care related activities, which could be beneficial to staff and residents. Staff also confirmed that resident’s religious needs were also met by visiting clergy, none of the current resident attended church. A staff member said, “Life for the residents is very flexible, they can have a lie in, go for a lie down during the day if they want and can have a bath when they want to”. Residents who are able to make their own daily life decision said that they could choose whether to remain the their rooms or use the communal lounges. One resident said that they spent some of their time reading, doing crosswords or watching tv. Visitors were observed during the inspection and it was confirmed that visitors were welcomed into the home. One relative said, “Even when we ring up, you are always put through to the people who have delivered the care and they give you lots of information”. Menu’s looked at during the inspection, one of the sets showed alternatives to the menu, whilst the other did not. It was however confirmed through discussion with the manager and operations manager that alternatives were always available to the residents. The operations manager also confirmed that during visits to the home, he had seen different meal choices for residents. There was some discussion about the use of condiments in the dining room. Both dining rooms were visited during lunchtime and none of the tables had condiments on them. The manager said that this was very unusual as they were readily available and usually in use in the ground floor dining room. The lunch-time observed in the upstairs dining room was not terribly conducive to an enjoyable experience and this could be improved to make it a more relaxed and enjoyable time. It was also observed that all of the equipment needed to promote independence and dignity was not available or in use at the start of the meal. Staff said, “the meals are good, there is a good variety and a balance diet”, “if you want an alternative, they just have to ask”. There were some mixed views from the residents about the meals, with the majority being more that satisfied with them. One resident said, “The food is fantastic, very tasty”, whilst another thought that the meals were more suited for older people and did not fully meet their individual preferences. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 14 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 are aware that if they had any concerns or complaints, these will be dealt with quickly and effectively and robust procedures are in place to protect residents from abuse although further staff training is needed. EVIDENCE: Residents and relatives said that if they had concerns they would speak with the staff or the manager about it. The complaints procedure was available for all who wanted to refer to it. The complaints records were looked at and contained appropriate information such as nature of complaint and outcome. The pre inspection questionnaire detailed that there had been one complaint in the last twelve months. One resident said, “There is nothing I am unhappy with, if I had any qualms I would speak with the staff”, “The staff team are excellent, they show the right attitude and respect”. The pre inspection also detailed that adult protection was a topic within the training programme. Previous discussion with the manager had confirmed that several training sessions had taken place regarding Adult Protection and would be ongoing. The training programme did demonstrate that this training takes place. Staff also confirmed that they had been involved in this training and had this understanding and awareness. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Residents continue to benefit from a very attractive, clean, homely and well-maintained environment offering spacious bedrooms with comfortable and well-decorated communal areas. EVIDENCE: Bramble Lodge provides a very pleasant, clean and well-maintained home for people to live. It provides a very good standard of living accommodation and continues to be well decorated and homely in all of the communal areas. Of the bedrooms visited, there was much evidence of personalisation and individuality, which included pictures, photographs, tv’s, video recorders and music systems. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 16 An extension is in the process of being built, which will increase the number of bedrooms in the home. The extension will also increase the communal space within the first floor unit, which will benefit the residents. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment and selection procedures that residents are generally supported and protected by a competent staff team. EVIDENCE: Three sets of staff files were looked at and two of the three contained the required information. The third staff file had limited information and related to a staff member who was employed in the home as a care assistant, whilst completing their qualified nursing adaptation course and their information was contained within the college files. The operations manager was satisfied that all of the necessary checks had been completed and that the placement was safe in terms of protection and well being to the residents. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 18 The duty rota was looked at during the inspection and detailed that throughout the day, two qualified nurses are on duty, one of which, continues nearly always to be an Registered Mental Nurse (RMN). When this was not the case, it is a Registered General Nurse (RGN) who had worked for the organisation for a substantial number of years and was deemed to have the required knowledge, skill and experience. In addition, there were also five care assistants on duty although there had been occasions when this had been down to four, which is in the process of being addressed. Night-duty is covered by one RMN and three care assistants. In discussion with staff and residents, they were satisfied that the number and experience of staff on duty was sufficient to meet their needs. One member of staff said, “You have time to sit down with the residents, you can spend time with them”. Training records were looked at and although ongoing training could be demonstrated, it was not clear how up to date staff were in terms of this. There was quite a lot of discussion about the training records and training plan. It was agreed that the records should be amended to show when staff had completed training and when it was next due. Staff confirmed that they had been involved in a range of training, such as dementia care; challenging behaviour; fire safety, infection control and moving and handling. The induction process was discussed with the manager who confirmed that all new care staff who had not attained a National Vocation Qualification (NVQ) in care commenced the Skills for Care Induction standards within one week of starting their employment in the home. The pre inspection questionnaire detailed that 48 of care staff are trained to NVQ II; this was also confirmed with the manager. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. Bramble Lodge is a well run home. The staff supervision system needs to be fully introduced to ensure all staff receives regular supervision. Quality assurance systems have not been fully implemented and do not demonstrated that the home is run is the best interest of the residents. As small number of records need more detail to ensure ongoing health, safety and welfare of residents. EVIDENCE: The manager of the home is registered with CSCI and he is a Registered Mental Nurse who has the required qualifications and experience to manager Bramble Lodge. Residents and relative spoke highly of the manager. One relative said, “The manager is very good, he listens and works with us, it doesn’t matter what you ask for, you get it”. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 20 One resident said, “It is top of the range here, you don’t need anything, it is all seen to”. Another resident said, “I see the manager everyday, he always has a few words with me”. Staff said, “The manager is always available for advice and I definitely think the home is well run”. Some staff spoke of the difference in the last six months in the home, where they believe that communication has greatly improved, which has positively impacted upon work life for the staff and care for the residents. A random sample of resident’s personal allowances were looked at. The systems for looking after resident’s personal allowances are good with the appropriate records in place. Supervision was discussed with the manager, and it was confirmed that although this was taking place that it was not always at the required interval. Mandatory training was discussed and the records looked at are as detailed within the staffing section of the report, records are to be developed further so that they clearly demonstrate accurate training for the staff. The pre inspection questionnaire detailed that the maintenance and servicing of equipment such as fire systems and emergency call systems are up to date. A random sample of in house maintenance records were looked and these need some further detail. There is the need to ensure that safety check take place as the required regular intervals. It was noted that the water temperature were not being properly recorded and there was the need to consider increasing these checks in respect of baths and showers. It was also unclear how frequently fire drills were taking place and the records that were in place did not always detail the staff who attended or the effectiveness of the drill. Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 14 Requirement Individual assessments must continue to be developed further, which include preferences, likes, dislikes and more detail about health and care needs. There must be evidence of service user/ representative’s involvement. Risk assessments must contain more detail. 2. OP9 13 The administration of medication must be reviewed to ensure that medication directions are accurate and also to ensure that correct procedure are being followed in regard to administration of medicines with accurate corresponding records. 01/06/07 Timescale for action 01/08/07 3. OP15 16 4. OP38 18 The management of meal-times 01/06/07 must be reviewed to enhance the dining experience for the residents and to ensure the equipment needed to ensure independence and dignity is in place at appropriate times. Records should be in place to 01/07/07 DS0000061455.V335338.R01.S.doc Version 5.2 Page 23 Bramble Lodge Care Home demonstrate that all staff are up to date with their mandatory training. Checks on water temperatures must be carried out more frequently and recorded. Fire drills must be carried out to ensure that all staff have been trained and this must be recorded. 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 recreation/social activities programme should be developed in accordance with detailed social and lifestyle assessments of all individual residents. Training records should be developed further to show all training that staff have received. The quality assurance systems should continue to be further developed to include additional customer satisfaction questionnaires and to make the results of any questionnaires available to relatives and residents. The planned programme for staff to receive formal supervision six times per year should continue to take place for all staff. 2. 3. OP30 OP33 4. OP36 Bramble Lodge Care Home DS0000061455.V335338.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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