Inspection on 08/02/06 for Bramerton

This inspection was carried out on 8th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 2 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 17/10/06

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 Stewart Mynott Unannounced Inspection 8th February 2006 10:45 Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 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.V281490.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V281490.R01.S.doc Version 5.1 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.V281490.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: The home is owned and run by CHOICE Ltd and provides care for people with multiple needs. The home is in a large detached house on the outskirts of a village. The house is set in a large garden, to the front is a secure gate with a tarmac car park and shrubbery and the rear is a large grassed area and patio. There is a large shed that is split into 3 distinct areas used for various activities. The house has three floors; residents’ rooms are on the first and second floors. All of the residents have individual rooms, of varied size and shape. The ground floor houses 2 lounges, the dining room and kitchen plus there are three further seating and recreational areas in the cellar. Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during the weekday lasting for 5 hours. The purpose of this visit was to look at how individual needs and choices of service users are met, how the home responds to complaints, staff training and the management arrangements at the home. Time was spent with service users, staff on duty and the registered manager. Records in relation to the care of service users and records in relation to the running of the home were also examined. What the service does well: 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.V281490.R01.S.doc Version 5.1 Page 6 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.V281490.R01.S.doc Version 5.1 Page 7 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): Standards 1 to 5 were not assessed during this inspection. EVIDENCE: Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 8 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 and 7 Service users current care plans were not available within the home. It is a requirement that there is an up to date plan of care kept in the home for each service user. Service users are assisted by staff to make decisions about their lives according to their abilities. EVIDENCE: The current individual care plans for all service users were not available during this visit. The registered manager informed the inspector that these were at a senior staff member’s home address to be typed up following their review. It was noted that these were also not available for the same reason in November 2005 during the previous inspection. The registered manager assured the inspector that he would endeavour to ensure these are returned to the home as soon as possible. Previous care plans were available at the home for staff’s reference. The registered manager confirmed that each service user has had an annual service review and an intermediate review. Four service users reviews were examined and clearly reflected changing needs, outcomes and resulting action plans that had been identified. Key workers and a day services staff member Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 9 confirmed their participation in preparation and attendance in such reviews, which include families and professionals involved in each service users care. In addition there are clear guidelines for the support required by service users including management of identified behaviours. Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 10 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): Standards 11 to 17 were not assessed during this inspection. EVIDENCE: Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 11 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): Standards 18 to 21 were not assessed during this inspection. EVIDENCE: Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 12 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 and 23 Service users views are listened to and acted upon by a knowledgeable staff team. Service users are protected from self-harm and abuse through robust policies and procedures that are understood by the staff team. EVIDENCE: There is a comprehensive “procedure on reporting complaints” contained both within the home and statement of purpose. Staff spoken to had a good understanding of how to respond to complaints. Staff spoken to confirmed that most service users would be unable to complain directly or access the complaints policy without assistance. Staff were able to demonstrate their knowledge of service users to ascertain if they were unhappy and would attempt to resolve any issue quickly. One service user spoken to did confirm that they would speak to the registered manager if they had any complaint. The complaints records book was examined and contained two complaints since the last inspection. One had been appropriately investigated and resolved. Another complaint was still currently being investigated in accordance to the Providers own procedures. Staff on duty spoken to were able to demonstrate a good understanding of protection and abuse issues and confirmed that they had received training in this area. Staff training records showed that most staff have completed protection of vulnerable adults training. Some service users can display verbal or physical aggression at times. Clear procedures in relation to the management of such aggression was viewed for two service users. Staff spoken to were able to demonstrate a clear understanding of these specific procedures associated with such behaviour. Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 13 During the course of the inspection behaviours were dealt with appropriately in line with established procedure including identifying triggers to prevent further escalation. “Behavioural observation charts” are completed by staff that record all challenging behaviour exhibited and completed records were viewed for two service users. Forms are completed when any authorised restraint/intervention is required. The registered manager confirmed that these are reviewed on a weekly basis by the in-house psychology team. Staffs training records demonstrate that staffs have received training in this area to include SCIP procedures. Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 14 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): Standards 24 to 30 were not assessed during this inspection. EVIDENCE: Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 15 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 and 35 Service users assessed needs are being met by a competent and trained staff team. EVIDENCE: The registered manager with information taken from the rota demonstrated that there are twenty-three care related staff currently employed (excluding the registered manager). The registered manager confirmed that eight staff have completed at least an NVQ level 2 and a further nine staff are currently in progress. The home is on course to reach the 50 qualification ratio. Staff at the home confirmed that they had completed a wide range of training to include mandatory topics and more specific courses relevant to the assessed needs of the service users. Most staff confirmed that they had attended training to use Makaton but further courses would benefit their confidence. Training records for the staff team were viewed and each staff member had a “staff profile”. The deputy manager who coordinates the booking and monitoring training had maintained these. The training records demonstrated a good range of training. One staff member discussed their experiences surrounding their induction to the home. They confirmed that they had been appropriately mentored and completed an induction booklet and had received regular supervision. Completed induction documentation for two further staff members were viewed and completed. Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 16 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 and 42 Service users benefit from an experienced and qualified and manager in charge of the home. There is an effective and meaningful quality assurance system to seek the views of service users, their representatives and staff to measure the success of the home in relation to its aims and objectives. The health, safety and welfare of service users are promoted and protected through appropriate monitoring and effective systems. The registered manager must arrange training to ensure all identified staffs receive an update in relation to fire safety training (including all night staff). EVIDENCE: The registered manager has been in post for about eleven years and is highly experienced and has gained all necessary qualifications in respect of his post to include the registered managers award. Questionnaires were sent out recently to seek the views and experiences of service users, their representatives, allocated care managers and staff in respect of the service. The results have been collated at head office and had Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 17 just been sent to the registered manager who was able to show the inspector this report. The report was mostly positive and contained comments to assist the registered manager to review the results against the aims and objectives of the home and develop an action plan as required. The provider representative conducts unannounced regulation 26 visits that are thorough and review the quality of the service provided and records kept within the home. The records generated from these visits are open and honest and are of an excellent standard. The health and safety arrangement for service users and staff were examined in detail. Staffs spoken to were clear in regards to their responsibilities in this area. Training is available and provided for staff to include all mandatory training topics to ensure health and safety of service users. It was noted that a significant proportion of the staff team had not completed refresher training in relation to fire safety training in some cases since 2003. In particular night staff records revealed that fire safety training had not occurred for some time. It is a requirement that arrangements are made for staff to undergo regular fire safety update training. The home benefits from an external agency that completes a thorough assessment and audit for the health & safety arrangements within the home. This was last completed in July of last year. Samples of records kept in the home relating to health & safety were examined to include fire alarm and equipment testing, water temperature testing, boiler servicing, electrical testing, COSSH assessments and risk assessments in relation to safe working practises. These records were maintained and up to date. The recording of accidents for service users and staff was examined. The last three accidents were case tracked and all relevant records had been completed. Advice was given to the registered manager in relation to storage of accident reports in line with the Data Protection Act. Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 18 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 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 4 X X 2 X Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 19 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 YA6 Regulation 17 Requirement The registered manager must ensure that service users current care plans are available within the home at all times. The registered manager must arrange training to ensure all identified staffs receive an update in relation to fire safety training (including all night staff). The dates of this training are to be sent to the CSCI in writing. Timescale for action 28/02/06 2. YA42 23(4)(d) 12(1)(a) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bramerton DS0000011296.V281490.R01.S.doc Version 5.1 Page 20 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.V281490.R01.S.doc Version 5.1 Page 21 - 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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