Inspection on 30/06/08 for Bramblegate

This inspection was carried out on 30th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bramblegate 21/05/07

Bramblegate 26/10/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Bramblegate 92 Ringwood Road Walkford Christchurch Dorset BH23 5RF Lead Inspector Tracey Cockburn Unannounced Inspection 30th June 2008 11:15 Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramblegate Address 92 Ringwood Road Walkford Christchurch Dorset BH23 5RF 01425 276846 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) Principle Care Ltd Mr Mark Richard Hulme Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st May 2007 Brief Description of the Service: Bramblegate opened as a residential care home in December 2005. It was one of three homes owned and run by Principle Care Limited. In June 2008 Principle Care Limited was purchased by Active Care Partnership part of Southern Cross Healthcare. There is currently no registered manager of Bramblegate. It is a detached house situated along a main road in Walkford. The property is in keeping with the neighbourhood. The home is registered to provide accommodation and support for four adults who have a learning disability. The philosophy of the home is to provide support to individuals who are moving onto greater independence. It is a family-style home and all four bedrooms are single with en-suite and kitchenette facilities. Three bedrooms are situated on the first floor and one bedroom is on the ground floor. There is a lounge / dining room area, separate kitchen and a garden to the rear of the house. There are areas for parking at the rear and side of the property. There is also an office which doubles as a staff sleep-in room. Local shops are within walking distance and there is a bus route into the neighbouring town of Christchurch. Fees charged by the home are variable and are assessed on an individual basis according to the needs of the person. The current scale of charges, vary from £900 - £1600 per week. For further information on fair fees and contracts access the website: www.oft.gov.uk Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was unannounced. A total of 4 hours were spent in the home over 2 days. On the first day there were no people living in the service available as they were all out. Therefore the visit on the 2nd day was specifically to talk to people living in the home. At the time of the inspection there were 3 people living in the service. 2 people were happy to talk about the service and 1 person chose not too. In the weeks before the inspection the registered provider sold the company to Active Care Partnership and staff were coming to terms with this change as they found out as the sale was completed. The registered manager at Bramblegate had been one of the directors of the company. The deputy manager has been promoted to the role of manager. During the inspection the manager was present and able to answer questions. The Annual Quality Assurance Assessment (AQAA) was requested by the commission and the current manager said it was received as he had seen it. However it had not been completed by the then registered manager. Survey forms were sent as part of the planning process of the inspection unfortunately none were received back from either people living in the service, their relatives or staff working in the service. During the inspection the records of people living and working in the home were seen as well as training records, fire records, medication and quality assurance records. A tour of the home took place. What the service does well: People who are considering moving into the service have their needs and aspirations assessed which means everyone can be clear about whether the home is able to meet someone needs. People tell us that they are able to make decisions about their daily lives with support. People living in the service are involved in activities, which interest them in the local community. They tell us they enjoy these activities with their friends. People tell us they can see family and friends when they want to. Records in the home demonstrate that people participate in and take responsibility for their daily lives such as choosing an activity; having access to all parts of the home and being responsible for house hold tasks such as cooking and laundry. People tell us they are supported in the way they prefer and their care plans reflect this. Records are kept of how people’s physical and emotional needs are met. The home has a complaints policy in place and people say they feel Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 6 listened to. Recruitment procedures are followed correctly ensuring that people living in the home are protected. What has improved since the last inspection? What they could do better: At the end of this inspection there are 8 requirements and 6 recommendations. Although recruitment procedures are robust and protect people in the home staff do not all receive training in safeguarding adults which means that they do not all know how to ensure that people living in the home do not come to harm or are abused. A failure to maintain the building means that windows are not protected from the elements as the paint is flaking and the furnishings in the home are worn and dirty which means the home is not as comfortable as it should be for the people living there. The registered provider has appointed a manager but has not informed the commission and the manager has not submitted an application to the commission to become registered. The quality assurance process has not been fully realised which means that people living in the service can not be confident that their views and opinions are listened to and inform the development of the service. The registered provider has not maintained records in the home, which would demonstrate that the home is being run in a way, which would demonstrate they were being safeguarded. The provider has not been undertaking monthly visits. Staff training in safe working practice has not been maintained and there are gaps in training, which means that the health, safety and welfare of people living in the service are not being maintained. Fire records also have gaps in safety checks. People living the home have individual plans of their care however they are not in a format, which is individual to each person. Risk assessments need to be more specific in order to ensure that people are supported properly. Staff need to be more proactive in ensuring that people living the home understand why healthy menus are important to them. Staff have to receive training in the safe handling of medication to ensure that people living in the home are protected. National Vocational Qualifications are important in ensuring that staff are competent to do the job. Staff should have equal opportunities training to ensure that people living in the home have their needs fully met. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 7 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. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who are considering using this service have their needs assessed before they move in so that a decision is made about whether the staff have the skills and training necessary to meet an individual’s needs. EVIDENCE: The records for one person were reviewed for evidence of assessment documentation. There was an initial assessment, which had been undertaken prior to the person’s admission. This included information about the person’s history, previous care, education, health, disability, medication, likes and dislikes, personal support needs, communication and behaviour. There was also information on file about the person’s expectations of the placement. The information from the funding authority was up to date and there was evidence of a multi disciplinary approach to the persons care. There was also evidence of a recent review of the placement. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service have individual plans, which reflect their needs and goals. They are able to make decisions about their own lives and risk assessments support them in their choices. EVIDENCE: 1 care plans was seen, this contained information based on the assessment and set out the specialist needs of the individual. The care plans was not in a format, which would help the individual understand the content of the plan. A total communication board is used for daily activities such as when the person is going out and what activities they will be doing but this is not reflected in the format of the care plan. The care plan had been recently reviewed and the care manager and community psychiatric nurse were happy with the placement and progress made. The views of the individual were included in the review. Staff record in the daily records choices and decisions made and these are clearly recorded in the care plan. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 11 Risk assessments are in place and contain detailed information on activities and possible risks. However there were some general statements such as “ high level of supervision” “ close” supervision with no specific detail as to how many staff this would be or what they were expected to supervise. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the service are encouraged to lead the live they want to and are supported to participate in activities, which interest them. EVIDENCE: People who live in the service spoken said that they have opportunities to engage in a variety of activities. 1 person said that they were on a summer break from college and looking forward to relaxing. On the second day of the inspection 2 people who live in the home were going out to do activities they were interested in 1 person was going out with 1 member of staff. 1 person spoken to said that they make use of local facilities including shops, markets, the cinema, pubs and leisure centres. Bramblegate does not have its Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 13 own vehicle to access the local area but service users stated that they go out in staff vehicles. 1 person spoken to said that they could do what they want to do during the day, in the evenings and at weekends. People said that they enjoy a variety of leisure activities in their home. There is a television in the communal lounge. 1 person said that he has a television in his room where he can relax and watch DVDs. People living in the home recently went on a week’s activity holiday with staff to Devon. People are encouraged to take responsibility for maintaining their home environment in terms of domestic tasks and cooking. A rota has been developed with input from individual’s to ensure that the allocation of tasks is fair. Individuals can participate in meal preparation on a daily basis supported by a member of staff. Meal options are discussed at weekly house meetings to ensure that individuals have the opportunity to choose what they want to eat. 1 person spoken with stated that the food offered at the home is good. The fridge and freezer were stocked with a variety of foods. The manager said that they take people who live in the service shopping each week. The house meeting minutes demonstrated that they are trying to encourage people to eat more healthily by choosing fresh vegetables not just the same favourite meals. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are supported in the way they prefer and their physical and emotional needs are met. Lack of training in safe handling of medication means that people are not fully protected. EVIDENCE: The people who live at Bramblegate are largely independent with regards to many aspects of their personal care. The ethos of the home is therefore to promote this by supporting service users to build on their skills in this area. Care plans detail the individual preferences of when to get up, the routine they prefer and how they like to be prompted and supported. There was evidence on the file seen that the individual was supported to attend appointments regarding both physical and mental health. However there was not always information regarding the outcome of the appointment. There was a detailed care plan in place regarding specialist care needed in relation to the individual’s health. However staff have not had any specialist training in this area. There was evidence that there are visits from the community psychiatric nurse. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 15 1 person said that they had recently had an eye test where they had to have new glasses. The individual support plan for one person was seen and showed evidence of liaison with both generic and specialist health care services to ensure the service user’s needs are met including the Primary Health Care Team, Psychiatry, Psychology and Dentist. A log of medical appointments was in place. Discussion with 1 person about their health care needs demonstrated that they were aware of issues relevant to them indicating that staff are making efforts to educate them about their health needs and discuss the outcomes of their appointments with them. A monitored dosage system in blister packs was introduced in March 2008. Medication administration record charts showed evidence that they are checked each time they are printed to ensure that the information they contain is accurate. Each record has a photograph of the service user on it to aid identification and the allergies of service users had been listed. A sample of medication was checked against the medication administration records and was seen to be correct suggesting that medication had been given as prescribed. There are 2 signatures on the MAR sheet that of a member of staff and the person receiving the medication. There was a medication support plan in place for 1 person living in the home. The home has a policy in place on the control, administration, selfadministration, recording, safekeeping, handling and disposal of medicines. In-house training is in place for all staff and there was evidence to indicate that training has been sourced from a local college and pharmacy to provide further education for staff in this area. However there are still gaps in staff training with 14 people who have not had any training in the safe handling of medication. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People tell us they are listened to and their views acted upon however there is little information about how concerns are dealt with. Safeguarding training has not been provided for all staff working in the home, which leaves people at risk. EVIDENCE: The home has policies on ‘Concerns and Complaints’ and ‘Whistle blowing’ to which staff are introduced at induction. 1 person spoken to said that he knew how to complain and who to speak to if he was unhappy. House meetings are held on a weekly basis where issues relating to the home can be discussed. The minutes for 1 meeting were seen they mostly seem to discuss outings and menus. The home has a policy on ‘Adult Protection and the Prevention of Abuse.’ This highlights the role of key agencies in dealing with adult protection issues. 8 staff had completed safeguarding adults training in July 2008. However a further 21 did not seem to have had any training in this area. At the time of the inspection staff employed by Principle Care Limited do cover at the other 2 homes. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People live in a home, which has been neglected both inside and outside. EVIDENCE: The home is light and airy. It is clean and there were no offensive odours on the day of the site visit. There is a cleaning rota in place and people who live in the home are responsible for some of the household chores. There is access to the local community shops, which are a short walk away. The home is very similar to other houses in the street. The paintwork on the outside of the building is shabby and flaking off. At the time of the visit the premises are accessible for all the people who live there. The front door is not currently used as the main access to the house and the manager said that he plans to change that and tidy up the front of the house making it more inviting. The fencing at the front of the house was in need of repair. The sofa and chairs in the lounge were in very poor state, dirty marks on the covering of the sofa and the chairs. As well as the covering being very worn in Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 18 places. 1 person who lives in the home was asked what he thought of the state of the sofa; he said, “ Its not very nice is it”. The manager says that he has been given the green light to replace the seating and will be involving the 3 people who live there in making the choice. The carpet in the lounge was also stained. The net curtains in 1 bedroom were grey and had a stain, which looked like mould. The net curtains in the living room were also a little grey. There was no evidence of a planned maintenance and renewal programme for the fabric and decoration of the home. The laundry room is locked during the day and contains the usual domestic machines seen in a small home. There are hand-washing facilities and the laundry floor is impermeable and the walls are cleanable. There is no evidence that staff have undertaken infection control training. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are supported by staff that know them well but to ensure their safety training and recruitment needs to be better. EVIDENCE: The core training checklist covers staff working at the other 2 services as well as Bramblegate and indicates that of the 38 staff employed over the 3 homes only 8 have had training in epilepsy, only 6 have had training in Autism. The 9 staff that have had training in epilepsy have not had any refresher training since 2006. The 7 members of staff who have had training in Autism have not had any refresher training since the initial training, in 1 instance in 1999. 1 person who lives in the service has needs for which staff have not had up to date training. 14 staff have not had any National Vocational Qualification (NVQ) training. 8 staff are currently working towards either NVQ 2 or 3. During the inspection staff were observed being respectful of individual people living in the home and their wishes. Because there are gaps in the training it is not clear if staff have the skills to support people living in the service. 7 staff Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 20 have not had any training in understanding physical and verbal aggression and methods of protection. However staff were observed listening to individuals and responding to their needs and using the guidance provided in their individual plans. The recruitment procedure for 1 member of staff was reviewed. There was evidence of 3 references being sought, a satisfactory Criminal Records Bureau (CRB) check as well as a protection of Vulnerable Adults (POVA) 1st check. There was also a copy of their contract with terms and conditions signed. There was also evidence on the file of training completed with certificates from previous jobs. 6 people are currently working towards the learning disability award according to the training checklist. The checklist says that only 3 people have completed this award. 6 people are currently completing induction but not other evidence was seen. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Changes in the ownership of the home mean it is not being run as well as it could be. Quality assurance process have started to be put in place however it is difficult to know if peoples views are being taken into account and are informing the development of the service. Some gaps in training mean that the health, safety and welfare of people living in the service are being put at risk. EVIDENCE: At the time of the site visit there was no registered manager for the service. The acting manager used to be the deputy and had been promoted by the new provider. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 22 There is no formal quality assurance process in place at Bramblegate to ensure that the quality of care is reviewed on a regular basis and an annual development plan is put in place. The new manager has started to put together a quality assurance file which he had available at the site visit. This contained a quality assurance plan, a maintenance log, house meeting minutes and complaints. The last staff meeting minutes are dated 21/01/08. These minutes cover staff in all 3 homes owned by Principle Care limited. 3 questionnaires had been completed and returned by people who use the service and they had signs, symbols and photographs to make the format more individual. There was also returned survey forms form 2 relatives and a care manager. The information had not been collated into a development plan. The core-training checklist covers moving and handling, first aid, fire safety, food hygiene but not infection control. No evidence was seen that staff have undertaken this training. The checklist shows that 6 staff have not had fire training, 4 staff have not had first aid training, 9 staff have not had manual handling training, and 5 staff have not had food hygiene training. There is no record of staff having infection control training. The checklist covers 38 staff that work across 3 homes covered by Principle Care Limited. At the time of the site visit there were no hazardous substance stored incorrectly. There was evidence that Portable Appliance Testing (PAT) had been taking place. Windows on the first floor are restricted. The manager has been completing the appropriate paperwork regarding notification of incidents and accidents to the commission. No regulation 26 visits have taken place since January 2008. However since the company was taken over by Active Care Partnership they have completed an audit of the home. The fire risk assessment is dated 15/06/06. There was no evidence of a review of this document. Weekly fire alarm and extinguisher checks were up to date although there was a gap in weekly checks between 15/03/08 and 26/04/08. This was the same for emergency lighting. There were 5 fire drills in 2007. The last fire drill was on 26/04/08. The fire alarm system was serviced on 19/06/08. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X 2 2 X Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13 (6) Requirement The registered provider must ensure that all staff receive the training they need which is appropriate to the work they do. To ensure that people are protected staff must have training in safeguarding. The registered provider must ensure that the maintenance programme is up to date and the paintwork on window frames is attended to. The registered provider must ensure that the furnishings in rooms used by people living in the home are of good quality, clean and in a good state of repair. The seating in the lounge is dirty and worn. The carpet is stained. The registered provider must appoint a person to manage the care home and inform the commission in writing of the name of the person and when they were appointed. An application to register the manager must be made to the commission DS0000065593.V362960.R01.S.doc Timescale for action 30/11/08 2. YA24 23 (2) (b) 31/10/08 3. YA24 16 (2) (c) 31/10/08 4. YA37 8(1)(2) 31/10/08 Bramblegate Version 5.2 Page 25 5. YA39 24 The registered provider must establish and maintain a system for reviewing and improving the quality of care provided at the care home. The previous timescale of 28/02/07 and 31/08/07 was not met. The registered provider must undertake visits to the home at least once a month unannounced. The visits must be recorded and interviews with people who live in the home and staff who work in the home must be recorded as well as the inspection of the premises. The written report must be available for inspection by the commission. The registered provider must ensure that the records specified in schedule 4 namely fire records are up to date and accurate. The registered provider must ensure that all staff working in the home receive training in the following areas: moving and handling, fire safety, first aid, food hygiene and infection control. 31/10/08 6. YA41 26 (2)(3)(4) 31/08/08 7. YA42 17 (2) 30/09/08 8. YA42 18 (1) (c) (i) 30/12/08 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 YA6 Good Practice Recommendations The registered provider should look at ways in which they can promote individual ownership of the support plans and ensure they are in a format that is meaningful for the individual and which they can develop in their own way. Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 26 2. 3. 4. 5. YA9 YA17 YA20 YA32 Risk assessments must be specific when describing the level of support and supervision someone needs. People living in the home should be support to understand and make healthy food choices. All staff working in the home should have up to date medication training to ensure that people living in the service are protected. The registered provider should ensure that at least 50 of care staff in the home achieves an NVQ in Care to Level 2 standard. The registered provider should ensure that all staff have received equal opportunities training. 6. YA35 Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Bramblegate DS0000065593.V362960.R01.S.doc Version 5.2 Page 28 - 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. 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