Inspection on 17/10/06 for Bramerton

This inspection was carried out on 17th October 2006.

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 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bramerton 25/06/08

Bramerton 29/06/07

Bramerton 08/02/06

Bramerton 21/11/05

Bramerton 07/10/04

Bramerton 22/07/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Bramerton Upper Bray Road Bray Maidenhead Berkshire SL6 2DB Lead Inspector Mrs Rhian Williams-Flew Unannounced Inspection 17th October 2006 10:00 Bramerton DS0000011296.V310470.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 Bramerton DS0000011296.V310470.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. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramerton Address Upper Bray Road Bray Maidenhead Berkshire SL6 2DB 01628 771058 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) stevenkaye@choiceltd.co.uk Choice Limited Mr Stephen A Kaye Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: The home is owned and run by CHOICE Ltd and provides care for people with learning disabilities. The home is a large detached house. A large garden surrounds the property and the front entrance has a secure gate. There is a separate building within the grounds that is used for various activities. The house has four floors; residents’ rooms are on the two upper floors. All of the residents have individual rooms, of varied size and shape. The ground floor has two lounges, the dining room and kitchen. The basement has three sitting areas. The Registered Manager has confirmed that the current weekly fees charged are £1291 - £1674. This includes the provision of day care services. There are no additional charges for any other services provided. The home has a detailed Statement of Purpose and Service User Guide and the Registered Manager has advised that there is a copy of the most current Commission for Social Care Inspection report available in the home for viewing. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used to inform this report includes a provider selfassessment questionnaire completed by the manager of the service; our inspection records held at the local office of CSCI; an unannounced site visit on 17 October 2006. The site visit took place between 10:00 hrs and 18:00 hrs and was conducted by one Inspector. During the unannounced site visit conversations were held with the members of staff on duty; a tour of the service was made; a random sample of case files were case tracked and some records concerning the management of the service were reviewed. The manager and Deputy Manager were present for the duration of the site visit. It was only possible to seek the views of two service users as the majority of service users do not converse verbally. CSCI did canvass the views of service users by asking them to complete a survey about their views of the care they receive. Three service users were able to participate in this. What the service does well: The home provides good information about the services it will provide; this information is available in pictorial images. The care needs of all the service users are clearly identified in care plans. Other professionals are involved in the development of these care plans offering particular advice on the management of challenging behaviours. There are clear risk assessment and risk management strategies in place for each service user. Service users are offered a wide variety of activities and daytime occupation. These activities are individualised to the service users particular interests and wishes. The service users are supported to lead healthy lifestyles. Their health-care needs are well monitored. The medication policy and procedures within the home are administered and monitored effectively. The Registered Manager is proactive in responding to complaints. His staff team also consider that he provides good leadership and is a good role model. The home has a full complement of staff they are enthusiastic and motivated. The service users who were able to converse commented very positively about staff members and the support they receive from them. Bramerton DS0000011296.V310470.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. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. Service users do have access to up-todate information about the home and there are procedures in place to ensure all new service users are thoroughly assessed. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The home does have an up-to-date Statement of Purpose setting out the aims, objectives and philosophy of the service it also has a Service User Guide. A copy of this is available in pictorial images. The service users who live in this home have all resided there for approximately 20 years. There have been no new admissions during this time. However, the Registered Manager was able to evidence the policy and procedure developed by the provider organisation to ensure that any new service user who would be considered for admission in the future would have their individual needs and aspirations identified and assessed before being offered an opportunity to live in the home. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. Service users care plans are up-to-date and identify their needs. Risk assessments and risk management strategies are in place however, all members of staff do need to familiarise themselves with these assessments. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: A previous requirement has been met. All service user care plans are present in the home. The Registered Manager also confirmed in the provider selfassessment questionnaire that each service users care plan was in place and key worker reviews are held each month to ensure that service users choices are respected. Six monthly reviews are held to ensure that the service users changing needs are reviewed. Yearly reviews also occur and involve the care manager from the funding authority. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 10 During the site visit 4 service user records were reviewed in detail. They contain up-to-date and relevant information regarding the service users care needs and how these were to be met. A significant number of the service users have limited or no verbal communication. This area of need was clearly supported in their care plans. A significant number also have challenging behaviours, which were clearly detailed and strategies on how to manage these behaviours were identified. There was clear evidence in the care plans that service users are encouraged wherever possible to make decisions about their lives. This was only limited if there was concern about harm or risk to the person or other people. If such a decision has been taken then risk assessments and risk management strategies were noted to be in place. Some of the service users at this home are and have presented significant risks, particularly to themselves. The risk assessments seen for these service users were detailed and gave clear guidance on how to manage the risk. To ensure that all staff understand these risks and how to manage them, the home have developed an audit mechanism of asking staff to date and sign to say that they have read and understood the present risks for service users. However, it was noted that for a number of service users, who presented significant risks, at least 25 of the staff team had not signed the audit mechanism that was in place. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. Service users are provided with opportunities for personal development and meaningful occupation. However, the cultural and religious needs of clients must be observed. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: There was good evidence in the service users care plans that they are given opportunities for personal development. If they express a particular interest or wish to participate in an event or activity then there was evidence that this was provided. However, at least 3 of the service users had particular cultural, religious and ethnicity needs. Their needs had not been properly identified in their care plans. This deficit must be addressed. However, at least 3 of the service users had particular cultural, religious and ethnicity needs. These needs had not been identified in their care plans. This deficit must be addressed. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 12 The provider organisation has developed day-care services, which are run at the home (but in a separate building) by identified day-care staff. The daycare service programmes for each of the service users were reviewed and there was an opportunity to discuss the programmes with the day-care services coordinator as well as one of the service users. The day-care services for each service user are tailored to specifically meet their needs. The range of activities and opportunities are good. A number of the activities involve using local community facilities. For example, swimming, horse riding, tenpin bowling, trampolining, visiting restaurants and attending discos. On the day of the site visit one of the service users visited the London aquarium, as this was a particular interest for them. From the random sample of care records that were case tracked there was evidence that service users are supported to maintain their family links and friendships. One service user was able to describe the visits they make to the family home and the things they enjoy doing when they get there. Observations during the site visit demonstrated that members of staff are very responsive to the service users wishes with regard to their daily routine. A few service users had chosen to get up later and enjoy a leisurely breakfast. Members of staff spoke respectfully to the service users and preserved their dignity when their behaviour became challenging. The home has a secure gated entrance and a keypad lock secures the front door. This level of security has been risk assessed and considered appropriate by the provider in order to safeguard the service users. If service users wish to use the front garden this is permitted either with a member of staff in attendance or, if their risk assessment permits they are able to visit the area without an escort. The back garden area can be freely accessed through french doors from one of the lounges. The evidence provided in the provider self-assessment confirms that the menus provided are nutritious, varied and balanced. At least 3 of the service users have cultural and religious requirements with regard to the food they are offered. The Registered Manager acknowledged that these dietary requirements have not always been observed by the staff who prepare the meals. The Registered Manager gave his commitment to addressing this matter promptly. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. Service users health-care needs are regularly reviewed. Specialist services are accessed for them whenever required. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The provider self-assessment identifies the all personal care is given in privacy either within service user bedrooms or bathrooms. The Registered Manager confirmed that some service users require minimal support such as, verbal prompts whilst others require more assistance. No aids and adaptations are required to assist service users. The provider self-assessment identifies that all service users receive regular health checks and if required, the involvement of other professionals is facilitated. The services of a psychologist and psychiatrist are available to the service users as the provider contracts with individuals from these professions. These professionals are involved in the development of the service users care plans and risk assessments. All of the service users are registered with the local GP who the Registered Manager confirmed knew the service users well Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 14 and was responsive to either seeing them at the surgery or providing home visits. The service users care plans certainly reflect that their health care needs are monitored well. One of the senior members of staff is responsible for the management of the medication within the home. This person was interviewed with regard to their role and the tasks they perform to ensure that the homes policies and procedures with regard to the receipt, recording, storage, handling, administration and disposal of medicines are complied with. From the evidence seen at the site visit all of these areas of medicine administration are monitored well. The dispensing pharmacist visits the home every four months and conducts an audit of the systems in place. There was good evidence that any recommendations made by this pharmacist have been acted upon. An area to consider for the revision of practice involves the medication is held by staff when service users of taking part in community activities. Presently, the medicines are not labelled to advise whom it belongs to, what the product is or its dosage and frequency of administration. Good practice advice is that this should occur. The Registered Manager and senior member of staff responsible for medication acknowledged the importance of this issue. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. Service users are protected by a robust procedure for safeguarding them. The home is also responsive to any complaints received. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The provider self-assessment indicated that there have been 5 complaints since the previous inspection, which had been resolved. These were reviewed at the site visit and it was noted that the Registered Manager had taken a proactive stance in resolving the complaints in a timely manner and to the satisfaction of the complainant. The provider self-assessment also confirmed that the complaints procedure has been produced in a text and picture format that is simple and straightforward to understand and can be used by the service user group. Of the staff members spoken with all were able to demonstrate their understanding of the procedures for safeguarding vulnerable adults. Members of staff are receiving training with regard to safeguarding vulnerable adults, the exception being the most newly appointed members and staff. However, the Deputy Manager was able to evidence that these training needs have been identified to the training officer. In the provider self-assessment they identified that in the past 12 months there have been 54 incidents of restraint. During the site visit it was evidenced that a significant percentage of these incidents had occurred with Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 16 one service user. There was clear evidence that the care needs of this service user are regularly reviewed. All members of staff have received training for the restraint technique. Bramerton DS0000011296.V310470.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is poor. The home needs to be kept in a good state of repair. Damage to the fabric of the building must be addressed promptly particularly to ensure the safety of the service users and members of staff. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The provider self-assessment indicated that in the past 12 months a considerable amount of furnishings, carpets and curtains within the home have been replaced. Some decoration has also been undertaken. The selfassessment indicated that the environment receives heavy use because of the service users many challenging behaviours. The Registered Manager also indicated that the provider organisation were reviewing the use of the building and were considering some changes to the environment. Some of these changes will include reconfiguration of bathroom and toileting facilities. The Registered Manager said that these changes have not yet been formalised. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 18 The home is very large, with the exception of some of the bedrooms. There are 4 communal lounges within the house and one lounge that is specifically designated for one service user. This amount of space allows the service users choice as to where they want to be. The service user rooms were seen and the provisions of furnishings within the rooms are guided by the risk assessments for each service user. Therefore, some rooms have more facilities and furnishings than others. It was evident that the fabric and furnishings of the building do receive significant use. This has resulted in the fabric of the building appearing to be shabby. As a result of the challenging behaviours of some service users radiators have been torn from walls and were awaiting replacement. The Registered Manager confirmed that decisions had been reached not to replace some of the radiators but to consider alternative means of heating. This will need to be resolved promptly before the winter period. The sensory room in the basement area is not being used as it is extremely damp and smells. Another sensory area adjacent to one of the basement lounges had badly damaged walls where plaster was crumbling away and could have presented a hazard to service users who used this area. Within this basement lounge one of the fire alarm bells was hanging off the wall. It was established that this had occurred on a Friday evening yet the matter was not reported to the contracted fire maintenance service until the Monday. In addition a member of staff did not test the fire alarms until the Monday. Whilst reviewing the service users rooms it was noted that at least two of the fire doors were not closing properly. This failure would have meant that the doors would not offer the recommended protection. It was established that the repairs had been highlighted to the maintenance department in the previous few days but problem had not been resolved. Service users and members of staff must have a safe place to live and work and repairs must be dealt with promptly. At the end of the site visit the Registered Manager confirmed that the fire maintenance service company had attended the home and repaired the fire bell and checked all the fire systems. In addition the maintenance man had attended and repaired the fire doors and checked the functioning of all the other fire doors. Ensuring the premises are kept clean and hygienic is important. The observations of the site visit indicated that this goal is only partially achieved. Some areas of the home clearly need more attention than others. The home does have separate laundry facilities. Bramerton DS0000011296.V310470.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. Service users are supported by a full complement of staff. However, members of staff must receive access to training. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The provider self-assessment confirms that the home has a full complement of staff. This was evidenced in the staffing rotas seen during the site visit. A significant majority of the staff are well established and experienced. The Registered Manager confirmed that thorough checks are made on all new staff taking up posts including CRB and POVA checks. The Deputy Manager is in charge of ensuring the training needs of staff are met. She was able to evidence that a number of staff have not received their mandatory training when it was due and in addition, for the past year members of staff have been unable to participate in NVQ training. The Deputy Manager was able to provide ample evidence of her attempts to access training for members of staff in these areas and the difficulties she has encountered. She was able to evidence that the issue related to the fact that there were insufficient places made available by the provider. Senior managers of the provider organisation must address this issue and requirements will be made Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 20 upon the Responsible Individual to resolve this problem promptly. The issue of staff not being able to access NVQ training appears to be resolving as the Deputy Manager was able to evidence that some members of staff have now been linked into a new training service. At the time of the site visit 32 of care staff have achieved NVQ level 2. The expectation is that 50 of the care staff should have achieved the qualification. The senior members of the staff team provide supervision to the other members of staff. Evidence was seen that supervision is occurring approximately once every two months and supervision records are kept. Of the members of staff spoken with all confirmed that they are keen to participate in training and felt disappointed when it does not come to fruition. All of them felt well supported by the staff team and expressed confidence in the Registered Manager and his abilities. They all had a very good understanding of the service users needs and how to manage any challenging behaviours they may present. Bramerton DS0000011296.V310470.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. A qualified and experienced Registered Manager manages the home. His leadership is positive. A previous requirement has not been met with regard to fire training and other mandatory training must be provided. This judgement has been made using the available evidence including a visit to this service. EVIDENCE: The Registered Manager is qualified and experienced to run the home. The members of staff spoken with have considerable regard for his leadership and consider him to be a good role model. The home does have effective quality assurance systems in place. The views of the people who purchase, use or visit the service are sought each year and the Registered Manager, on feedback given, subsequently takes action. Evidence was seen of actions being taken with regard to information coming from staff meetings. Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 22 As previously mentioned members of staff are not receiving mandatory training promptly enough. The Responsible Individual must address this. A previous requirement has not been fully met, as there is still one member of the night staff who has not received fire training. The providers’ self-assessment confirms that all the relevant inspection checks with regard to the safety of the building have been completed in the past year. The exception being the electrical wiring certificate which was last inspected in Dec 2002. The Responsible Individual must be satisfied that the electrical wiring in the care home is safe. During the site visit substances that could be hazardous to peoples health were on open display. A bottle of white spirit was not locked away. The Registered Manager immediately removed this but all members of staff must be vigilant to such hazards. Bramerton DS0000011296.V310470.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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 3 3 X X X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 3 X 3 2 3 3 X 3 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 1 X Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA11 Regulation 15(1) Requirement Timescale for action 30/11/06 2 YA17 16 (2)(i) 3 YA24 23 (2) (b) The Registered Manager must ensure that the cultural and religious needs of service users are recorded in their care plans and if the service users or their representative indicate these preferences must be observed. The Registered Manager 30/11/06 must ensure that the dietary requirements of service users are respected and provided for. This is particularly important for service users with specific cultural and religious wishes. The Responsible Individual 15/12/06 must ensure that the premises is kept in a good state of repair to ensure the service users can use all the facilities (this includes the sensory room); have a comfortably furnished and well decorated environment; that repairs are addressed promptly to ensure a safe environment DS0000011296.V310470.R01.S.doc Version 5.2 Page 25 Bramerton 4 YA24 23(2)(p) 5 YA24 23(4) 6 YA30 23(2)(d) 7 YA35 18 (1)(c) 8 YA42 12(1)(a) 9 YA42 23(4)(d) 12(1)(a) is maintained for service users and members of staff. The Responsible Individual should provide a detailed plan with timescales for action with regard to the refurbishment of this home. The Responsible Individual must provide information with regard to the provision of heating in all areas of the home used by service users and the timescale for providing it. The Registered Manager must ensure that the fire precautions within the home all function, as they are required to and, any repairs or malfunctioning are attended to urgently. The Registered Manager must ensure that all areas of the home are clean and hygienic at all times. The Responsible Individual must ensure that access to sufficient training is provided for all members of care staff. Members of staff must have access to training that is relevant to their role. Responsible Individual must ensure that access to mandatory training is provided for all members of care staff. A number of staff members urgently require this training. The Registered Manager must arrange training to ensure all identified members of staff receive an update in relation to fire safety training (including all night staff). The dates of this training are to be sent DS0000011296.V310470.R01.S.doc 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 30/11/06 Bramerton Version 5.2 Page 26 10 YA42 13(4)(a) to the CSCI in writing. THIS IS A REPEAT REQUIREMENT. The Responsible Individual should ensure that the electrical wiring in the care home is safe. 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA9 YA20 Good Practice Recommendations All members of staff need to, understand and sign the risk assessments that are devised in order to protect themselves and the service users. That service users medicines that are used whilst they are participating in activities away from the home should be clearly labelled with the name of the medication, its dosage and who is belongs to. The Registered Manager needs to remind staff of their responsibilities with regard to the control of substances hazardous to health (COSHH) to ensure the safety of service users. 3 YA42 Bramerton DS0000011296.V310470.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bramerton DS0000011296.V310470.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. 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!