Inspection on 04/09/07 for Bramley House

This inspection was carried out on 4th September 2007.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bramley House 18/09/06

Bramley House 29/11/05

Bramley House 01/08/05

Bramley House 15/11/04

Bramley House 18/05/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Bramley House Bramley House Bromley Green Road Upper Ruckinge Ashford Kent TN26 2EG Lead Inspector Sue McGrath Unannounced Inspection 10:00 4 September 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramley House Address Bramley House Bromley Green Road Upper Ruckinge Ashford Kent TN26 2EG 01233 732629 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) Rooks (Care Homes) Limited Post Vacant Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2006 Brief Description of the Service: Bramley House is registered to provide residential care for up to 18 older people and admits people with low to medium dependency needs. The company Rooks (Care Homes) Ltd owns the business. The Managing Director Mrs Caroline Rooks is currently not in day-to-day control. A manager is in place and has day-to-day control. She is not currently registered with the Commission. The premise is a detached property, which has in recent years undergone major refurbishment work including an extension with six en-suite bedrooms. There are 16 single bedrooms and one double situated on the ground and first floor. There is a stair lift to enable access for those with mobility problems. Six bedrooms have en-suite facilities and the others have a wash-hand basin. All rooms have a call bell and television point and a telephone is by arrangement. The residents have the use of three bathrooms. There is a spacious dining room, which includes a seating area in front of patio doors overlooking the front entrance. The residents have the use of two lounges one of which has a television. There is a well-maintained garden to the rear with a patio/seating area and a water feature with fishpond. The rear garden also includes an aviary with birds, rabbit, and guinea pig. There is a patio/seating area and parking to the front. The home is situated in a quiet rural area approximately 5 miles from Ashford. An infrequent bus service runs into Ashford from just outside the Home. The current fees range from £306.00 to £492.50 per week. There are additional charges for hairdressing, toiletries, magazines and newspapers and chiropody. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on 4th September 2007 and was conducted by Sue McGrath, Regulation Inspector for the Commission for Social Care Inspection. The key inspections for care home services are part of the new methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and further feedback is gained through surveys sent to service users and relatives and information provided from professionals associated with the home, wherever possible. The actual date of the site visit is unannounced. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Some judgements have been made through observation only. The home refers to the service users at the home as clients and this term will be used throughout the report. Overall this was a positive inspection with good outcomes for the clients. What the service does well: The atmosphere of the home is relaxed and comfortable. Clients confirmed they feel well cared for and respected by all staff. Very positive feedback was giving regarding the food, all said the quality and quantity provided was very good. Several commented favourably on the recent introduction of supper. The provider and manager have worked hard to develop new care plans that appear at this stage to be comprehensive and detailed. Staff confirmed they are easy to understand and to follow. Currently only five or six have been introduced and the next inspection should be able to confirm if they are a sound working document. The environment is of a high standard and the home is clean and tidy. The outside gardens give a lot of pleasure to many of the residents. The recent purchase of a mini bus has enhanced the daily activities of several of the clients as they can now enjoy outside trips and this has proved very popular. Staff show a commitment to a good level of care and appeared competent and understand to their roles. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients are provided with the information they need to make an informed choice about moving into the home. Clients benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Clients and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 9 EVIDENCE: Discussion with the manager confirmed that all prospective clients receive a copy of the homes Statement of Purpose prior to admission and a copy was seen in the foyer for general use. The homes service user guide was also freely available. All clients have a written contract/statement confirming terms and condition which is agreed and signed. This was confirmed by several of the clients. The assessment procedure was discussed and evidence seen of completed assessment forms. Staff also confirm they attend some of the assessments with the manager. These assessments are comprehensive and allow the home to make a sound judgement as to whether they can meet the prospective clients needs. Prospective clients and their families or representatives are encouraged to visit the home to view the amenities and facilities offered. Trial periods are offered before a decision to remain needs to be made. Intermediate care is not provided. The home does provide respite care bed vacancies allowing. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from having clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and the clients benefit from having full access to all professional health care services as required. Clients are protected by the home’s policies and procedures for dealing with medicines. The clients feel they are treated with respect. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 11 EVIDENCE: Since the last inspection new care plans have been developed and are in the process of being implemented. Of the seventeen current clients five or six have the new care plans and the manager is working to complete the remainder. The format of the new plans is good with comprehensive information available to staff. Staff confirm they liked the new plans and have been involved with their development. They also confirm that if they make suggestions about the format they have been listened to and the plans adjusted. This is an ongoing area of development that has made a promising start. When speaking to the clients few seem to have any knowledge of their care plans and the manager is strongly advised to involve the clients in the drawing up of the plans and to ensure they agree the contents. Manual handling assessments need to remain robust. Clients confirmed they feel well cared for and evidence was seen of regular visits from District Nurses, Chiropodists, Opticians and other health care professionals. Clients confirmed they could see their own G.P. when they needed to. Staff displayed a good knowledge and understanding of tissue viability and currently no clients were suffering from any pressure areas. Equipment necessary for tissue viability is available if needed. Resident’s psychological health is monitored and professional input obtained where necessary. Residents continue to be weighed monthly. Any action taken as a result of significant change is recorded. Advice was given regarding the completion of nutritional assessments. Daily notes are maintained and any visit form a health care professional is recorded and advise given was followed. Medication is supplied in a monitored dosage system. MAR charts reflected that medication is administered correctly with the appropriate use of codes. Staff that administer medication undertake a one day training session to administer medication safely. It is recommended that staff attend a more in depth training course. Staff confirm the manager does complete spot checks to ensure medication is being administered correctly. She is advised to record these spot checks and record the outcomes. Procedures are in place for the use of over the counter medicines. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 12 All of the clients spoken with confirm they are always treated with respect and staff maintain their dignity at all times. Several clients stated they preferred to stay in their own rooms and staff always respected this. Several preferred to have their meals in their own rooms. Some rooms have private telephones. Clients are called by their preferred name and privacy screening is provided in the shared room. The clients made some of the following comments: ‘The staff look after me very well- they are very kind and considerate’. ‘The staff are very helpful and pleasant’. ‘There are always lots of smiling faces about, that makes me feels better and happy myself. It is a happy place to be’. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from the flexible routines in the home and they are able to exercise choice in relation to routines of daily living. Clients social and recreational interest and needs are well provided for with a range of activities organised. Clients are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The clients benefit from the appetising meals and balanced diet offered by the home and those clients requiring specialist diets are well catered for. EVIDENCE: There is a relaxed and homely atmosphere within the home. Clients confirm they enjoy a flexible approach to routines and daily life. All of the residents when spoken with also confirmed they were happy with the current level of Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 14 activities, which they say have improved recently. The purchase of a mini bus has enabled staff to take some of the clients out on pub visits and to visit local garden centres. These trips were very much enjoyed by the clients and they are looking forward to having more trips out soon. The activities are mostly undertaken in the afternoons were a range of games and other activities are available. Staff say they ask the clients what they would prefer to do on that day. Records of activities could be improved, as it is not always evidenced that they are taking place, however the clients confirmed they normally do take place. One client said ‘ I enjoy what the girls do in the afternoons. There is nothing more I would like to do that I can think of’. Activities also include cooking sessions, manicures, one to one sessions, reminiscence and musical sessions. The home has one volunteer who also assists in the activities. One gentleman was extremely positive about the support he had received from both management and staff about his love of gardening. He had been enabled to go to a garden centre and purchase plants for the gardens, paid for by the home. He had been assisted to plant them and was responsible for maintaining and watering the plants. This is a role he clearly enjoys and gained much pleasure from. The garden looks very pleasant and extremely well maintained. Several other clients mentioned the lovely gardens and all seemed to gain pleasure from his endeavours. Feedback from relatives was very positive and residents confirmed that families visit frequently. Positive feedback was also received from Kent County Councils care managers. The main meal is at lunchtime and there is a good choice of dishes. All of the clients said the food is good and they enjoy the meals. Clients are encouraged to the dining room although meals can be taken elsewhere. Independence is promoted with vegetables and drinks available on individual tables so clients can help themselves. Supplies of fresh fruit were seen around the home and in the client’s bedrooms. Fresh vegetables are used where possible. The dining room is pleasant; tables are laid with linen tablecloths and napkins. Special diets are catered for. Clients are offered drinks of squash and tea and coffee etc through the day. Supper has recently been introduced and this is proving popular with the clients. Feedback from the clients regarding the food was very positive, some of the following comments were made; ‘The food is excellent’. ‘The food is good and we get a choice every day. We can have whatever we want for teas and also have a supper’. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 15 ‘I like all my meals in my own room- I prefer this. The food is very good and tasty’. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clients feel their views are listened to and any concerns would be acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The home has a formal complaints procedure with dedicated timescales available to the clients. The clients spoken with confirmed that they would have no problem with complaining to the manager or any member of staff and were certain issues would be addressed quickly. No formal complaints had been received by the home. There had been one Vulnerable Adults Protection alert since the last inspection but this had been dealt with quickly by the home. However the manager is strongly advised to ensure she follows the correct procedures. Regulation 37 reports are now being completed and the manager is fully aware of what and when to report. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 17 Several staff were spoken with regarding Adult Abuse and were able to confirm a good understanding and were aware of what and who to report to. Not all staff have received training in Adult Protection. The home does not hold or deal with client’s personal finances. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. EVIDENCE: The environment at Bramley House is well maintained, clean and tidy. The clients are able to use any of the lounge areas as they wish, they also confirm the dining area is pleasant and comfortable. Several of the clients confirmed they preferred to have their meals in their private rooms but insisted this was because they liked it that way and that staff were happy to oblige. As stated earlier in the report the gardens are very well maintained and several of the clients stated how much they enjoyed the gardens and Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 19 sometimes they had their teas outside when they weather was pleasant. Several said how mush they enjoyed looking at the wildlife, especially the birds. Several bird feeders were seen in the gardens. One concern was the suitability of the bath hoists. Several clients said they felt uncomfortable using them and staff also confirmed they had some minor difficulties. It is recognised that the bath hoists are regularly maintained but they are not permanently fixed to the floor, making then possibly unstable during use. They do not allow the clients to sit in them and then swing around into the bath. Now the level of dependency within the home has slightly increased, the provider needs to consider more suitable hoists. All of the clients spoken with confirmed they liked their rooms and that they were comfortable and also very clean. The majority have bought in personal items for their rooms that reflected their interest and hobbies; the manager confirms this is encouraged where possible. Not all radiators are fitted with low temperature guards in the bedrooms. These require a risk assessment. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients benefit from staff that are trained and competent to do their jobs, who enjoy good morale and who demonstrate an awareness of their roles and responsibilities. Clients are now protected by robust recruitment procedures. EVIDENCE: Rotas confirm that currently two members of care staff are employed both in the morning and afternoons. During the night one waking staff and one sleeping staff are on the rota. The home now employs a domestic every day of the week, including Sundays. This had improved since the last inspection. A cook is also employed seven days a week. The manager is extra to the figures above and currently lives on site. The recruitment procedure was discussed and evidence was seen that this procedure has improved. The manager confirmed that she interviews possibly with another member of staff and that notes are kept of the interview. Gaps in employment are now explored and the necessary references are obtained. All staff hold a current CRB check. The home does employ three overseas workers Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 21 as it has found difficulty in employing local staff. These staff are employed using an employment agency and are currently completing English courses at a local college. Some of the clients mentioned this when spoken with, but all were very positive about the outcome with one client wishing to learn Polish. A positive rapport had developed between the Polish staff and some of the clients. The home should endeavour to have at least one English speaking staff on at all times to ensure there are no communications difficulties between staff and clients. Of the nine care staff employed, five have completed NVQ level 2 or above. Three staff are waiting to start their qualification and have been booked onto the course and are waiting for a start date. Manual handling training was completed on June 2007 and infection control has been booked for October 2007. The majority of staff have completed Adult Protection but all staff are required to completed this course as soon as possible. Medication training is currently a one-day course mainly looking at the MAR system used in the home. It is recommended that a more in depth course be completed as soon as possible. Specialist training needs to be encouraged and some suggested areas should include dementia, diabetes and catheter care. All staff have completed a basic food hygiene course. Induction training is ongoing, with the manager recognising some staff need more time than others to complete the designated course. Staff spoken with on the day were committed, enthusiastic and focused on good outcomes for residents. Some staff that have a wealth of experience and knowledge particularly when dealing with complex care needs and it is apparent from discussions that other staff use these as a positive resource. All staff demonstrated a very caring attitude and said they enjoy working here. Resident’s comments were very positive about individual carers and the staff team as a whole. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The clients benefit from having a manager who is supported well by staff and who provides clear leadership throughout the home. Current arrangements were sufficient to protect the health, safety and welfare of residents and staff. EVIDENCE: The manager has recently completed the necessary qualification to become the registered manager and need to apply to the Commission to be registered. She stated this was a priority for her and that she hopes to complete the application as soon as possible. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 23 The current management of the home creates an open, positive and inclusive atmosphere and staff confirm they feel well supported by management and involved in the running of the home where possible. It is apparent that the manager has created clear lines of responsibility within the home and has encouraged staff to feel part of the team and to take responsibility for their roles. The provider does have an active role in the management of the home and completes regulation 26 visits. However, these visits should be completed monthly with a written report produced for the manager to retain. The last report was dated April 07. It is recognised that the provider did complete a visit in August. Consultation with the clients appears to be undertaken on an informal basis and needs to be formalised to comply fully with Standard 33 in that any results of service user surveys are published and made available to current and prospective clients, their representatives and other interested parties including the CSCI. The views of families and friends and of stakeholders in the community such as GP’s, chiropodists, district nurses etc should be sought and included in the report. The home does not have any involvement with the clients own monies and invoices for extras are sent with the normal monthly fees. Valid insurance cover was displayed within the home. Checks are made to ensure the building and equipment are in good working order and valid service certificates and records are in place. The home has received visits both from the Environmental Health Officer and the Fire Officer and both gave positive reports. The homes fire safety checks were looked at and the home is advised to record all fire drills as evidence that staff are aware of the correct procedures. One area of concern was the temperature of the water delivered to the client’s rooms. The water was very hot and one resident also stated it was ‘often too hot to rinse my hands in’. The home does not currently record room water temperatures and discussion took place on how this needs to be addressed. If the individual rooms do not have thermostatic mixers valves (TMV) fitted the home must evidence that the water is at a safe temperature. A full risk assessment will need to be undertaken. The water should not be discharged at more than 44 degrees centigrade. Guidance regarding water temperatures can be found in the guidance logs (p 110) provided on CSCI website. In the last report it was highlighted that fire doors were seen wedged open. The home is currently in the process of having sound activated door closures fitted and it is expected that this work will be completed by the end of October. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 24 Regulation 37 reports are now submitted by the home where necessary. Staff supervision is ongoing but needs to be formalised to comply fully with standard 36. The standard states all staff should receive formal supervision at least six times a year. Some staff stated they only received supervision every three months but did agree they could talk to the manager at any times. It is recommended that the system used be formalised and staff awareness raised of what supervision entails. All records need to be maintained to evidence that supervision is taking place. The manager is currently working through the policies and procedures to ensure they have been updated and reflect current good practise. Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 2 3 Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 26 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 OP31 Regulation 9 Requirement The home must be managed by a person with appropriate qualifications, skills and experience and be registered with the Commission. This has been carried forward form the last report. Timescale for action 30/11/07 2. OP33 26 The provider must visit the home 18/10/07 unannounced at least monthly in line with regulation 26 and produce a written report. This has been carried forward form the last report. The provider must ensure the health, safety and welfare of the residents in that water temperatures must be regulated. The provider must assess the suitability of the bath hoists provided taking into account the dependency of the service users. 31/10/07 3. OP38 13 4. OP21 23 31/10/07 Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. 2. 3. 4. 5. 6. 7. Refer to Standard OP18 OP7 OP30 OP33 OP9 OP30 OP7 Good Practice Recommendations All staff should receive adult protection training Risk assess residents where their bedrooms radiators are not already fitted with low temperature surfaces Staff to receive training in specialist subjects and in the interim an information folder should be set up for staff Review policies and procedures to ensure all subjects are covered as indicated on the pre-inspection questionnaire It is recommended that staff receive a more in depth medication training It is recommended that staff receive training in catheter care. It is strongly recommended that service users are involved in the drawing up of the new care plans Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Bramley House DS0000023350.V345684.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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