Inspection on 13/06/08 for Bramshall`s Old Rectory

This inspection was carried out on 13th June 2008.

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

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

Other inspections for this house

Bramshall`s Old Rectory 30/07/07

Bramshall`s Old Rectory 02/11/06

Bramshall`s Old Rectory 04/01/06

Bramshall`s Old Rectory 08/08/05

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

CARE HOMES FOR OLDER PEOPLE Bramshall`s Old Rectory Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST14 5DN Lead Inspector Joanna Wooller Unannounced Inspection 13th June 2008 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bramshall`s Old Rectory DS0000059275.V366286.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. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramshall`s Old Rectory Address Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST14 5DN 01889 565565 01889 565415 anil_r_patel@hotmail.com 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) Tudor Care Plc Care Home 30 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (15), of places Physical disability (20), Physical disability over 65 years of age (25) Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD minimum age 60 Years Date of last inspection 30th July 2007 Brief Description of the Service: Bramshall’s Old Rectory is a 30-bed Care home, providing personal care and nursing care to elderly persons over the age of 60 years. The home is registered to care for people with physical disabilities, needs associated with old age, or dementia related conditions. The home is situated in the village of Bramshall with good road access to Uttoxeter, some three miles away, in delightful country surroundings. Excellent views are afforded over the rolling Staffordshire countryside. The original buildings have been extended, lifts and stairs access the three floors. A homely environment has been created throughout. Hotel services and facilities including bathrooms, laundry and catering are good. Communal and lounge facilities are spacious and well furnished. The home has 26 single and two double rooms for married couples or those who prefer to share. Nurses and care assistants led by a Registered Manager, who is a first level nurse, deliver care. Staff training is given a high priority. Health service professionals such as district nurse, community psychiatric nurse, and physiotherapist are accessed when required. Local GP’s who are also pharmaceutical dispensing practices service the home. Activities, hobbies and entertainment all take place and transport is provided when required. Families and friends are encouraged to take part in activities and to be involved with the home. The home has not published its fees for residency in the Service User Guide. Readers of this report are asked to contact the home directly for this information. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the service, they were given no prior notice. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • • • • • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. We also spent time talking to the people who use the service and to the staff who support them. We looked at the care of three people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. What the service does well: What has improved since the last inspection? The home has worked hard to meet all of the requirements made at the last inspection. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 6 This means that Medication Administration Records (MAR) are being completed in such a way that audit is now possible. This will provide additional safeguards for service users. The registered provider is visiting the home on a monthly basis to complete the required quality visits. This will mean that they are aware of quality issues within the home and give people the opportunity to talk to the provider about their views and experiences of living in the home. The home now has a registered manager. This will mean that someone competent and capable is in charge of running the home and ensuring that it is run in the best interests of the people who live there. What they could do better: The home has not sent us the information we requested from them in the form of their Annual Quality Assurance Assessment (AQAA). They did not do this despite a reminder letter being sent to them. The registered provider was also sent a Statutory Requirement Notice asking them to provide us with the AQAA. We have still not received this document and are currently considering further legal action in relation to this. The home completes an assessment for each person prior to their admission however improvements are needed to ensure that at point of admission both staff and new service users are sure that their care needs will be addressed. The home will also need to make sure that people have an initial plan of care upon their admission. This can then be updated as the home and service users begin to get to know what they want. Improvements in health care screening have been recommended such as the introduction of a Nutritional screening tool and a falls risk assessment. These will help identify those people at risk and allow the home more time to take action to prevent deterioration in people’s conditions. Staff need to have training so that they understand the principles of the Mental Capacity Act 2005 and their roles and responsibilities in supporting people who may not have the capacity to make choices about their healthcare. Staff need refresher training in Safeguarding vulnerable adults to make sure their knowledge it up to date and they are aware of the processes and systems in place to protect people living in the home. Some of the home’s equipment needs to be reviewed and replaced in some circumstances. This is particularly relevant to the bed rails and pressure relieving mattresses in use in the home. The home must make sure that bed rails and mattresses are compatible with each other and the bed they are fitted to. This will reduce the risk to the people who use this equipment. The manager has told us that this is currently in the process of being done. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 7 Staffing levels should be reviewed given the dependency of the people living in the home. Some people require more help and assistance than others and staffing levels should reflect this. Staff told us “if we did have just one more person on duty it would help a lot, give us more time to be with the residents and not feel under so much pressure all the time”. 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. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 8 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 Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 9 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): 1,3,6 Quality in this outcome area is good. People can feel confident their needs will be assessed prior to their admission. The home will provide them will enough information to enable them to make choices about living in this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides information to all people who may be considering living here. There is a statement of purpose and a services user guide that outlines the homes aims and objectives and the services they provide. We have recommended they improve upon this by including information on fees people may be expected to pay. People do have their needs assessed prior to moving in the home. The home manager will usually visit them and discuss their needs. An assessment is completed and from this care can be planned. The home must however make sure that when people are admitted they do have an initial care plan in place Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 10 so that people can be assured their needs will be known to the staff. This will give them added confidence the home can meet those needs. The home does give people a contract of residency which outlines the terms and conditions of their stay. The manager has told us that privately funded people do have a review after three months into their stay. This is when the contract is usually given to people. It is recommended that people have a contract at the point of admission that shows the providers responsibility towards them and also gives clear information to the service user about the conditions of their stay. This home does not provide intermediate care facilities. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. The home does meet people’s healthcare needs but further improvements to individual record keeping is needed to ensure all needs are recorded and known to the staff. Medication practices are good and safeguard people’s interests. People living in this home can expect to be treated with respect and dignity at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care records of three people a part of our case tracking process. We saw that not everybody had a care plan upon admission. This was particularly concerning for one person as we saw that they had multiple healthcare issues that required attention. Such as catheter care, pressure area care and nutritional needs. The manager explained that this was because this person had only recently moved into the home and the staff had not yet completed them. We have said that all people admitted to the home must have care plans at the point of admission, once a person has settled into the home the plans can then be rewritten if their needs change in time. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 12 Staff take steps to identify risks to people such as moving and handling risk assessments and pressure sore risk assessments. We looked at these and found that they were not always kept under regular review (monthly) or amended as people’s needs had changed. It was pleasing to see that despite this people who were at risk have all the equipment they need to reduce risks to them. This includes pressure relieving mattresses and cushions and lifting hoists. In order to improve the risk assessment process in the home we have recommended the introduction of a falls risk assessment and a nutritional screening tool. This will enable the home to identify those people at risk and allow them to take preventative risk reduction measures rather than taking action once a problem has been identified. We noticed that not all of the people living in the home are being weighed regularly. This needs to be improved. If people are unable to use conventional weighing scales the home should consider the use of an alternate monitoring system. This will help ensure that peoples needs are being kept under review. Medication systems in this home are generally good and protect the people living here. There are some improvements to be made that would build upon the current good practice. The temperature of both the drug fridge and the treatment room should be recorded daily. This is to make sure that medication is being stored at temperatures recommended by the medicines manufacturers. If people are prescribed medication with a variable dose, for instance where paracetamol is prescribed “1 or 2” tablets to be given, staff must record the amount they administer. This will assist in the audit of medication. Handwritten Medication Administration Record (MAR) sheets must include all the information needed to safely administer medicine. For instance the dose of medication, the name of medication to be given, the route of administration and the frequency (how many times a day). We looked at how the home make sure that people’s privacy and dignity are upheld. People told us “my dear I couldn’t ask for any better, the staff are wonderful”, “they help me and I am happy here, I like it”. “if you need help the nurses are there to do it, I have no complaints”. The home also has good systems in place to care for those people who need end of life care. The Liverpool Care pathway has been introduced and this means that people who are in need of pain relief, respiratory care or other specialist care will get it. The home is supported by their doctors and the Macmillan nursing service in making sure that people are kept comfortable and pain free during the last days of their lives. The home also makes sure that people are informed and there families are involved. Bramshall`s Old Rectory DS0000059275.V366286.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): 12,13,14,15 Quality in this outcome area is good. People are encouraged to take part in activities and to keep themselves active throughout the day. Families and friends are encouraged to visit. Meals are of a good quality and people have plenty of choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home takes time to organise games, quizzes and other activities for people to take part in on a daily basis. Staff told us “sometimes people just don’t want to do it, they are tired and prefer not to, this is fine to”. “we all try an help, what you see here today is what you get everyday, the staff always try hard”. “We have help from the activity lady she makes sure that there is always something going on”. People are encouraged to see visitors when they want to. They have the choice to see them in the communal areas or they privacy of their own rooms. The home tries to support people in making choices and being as independent as possible. They support people by helping them manage their own money and provide people with lockable facilities in their rooms to keep valuable safe. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 14 We saw that people are also encouraged to make their room their own by bringing in their own possessions from home, rooms we visited were personalised with pictures, ornaments and favourite pieces of furniture in some cases. We discussed with the manager the provision of further training for staff so they were aware of the principles of the Mental Capacity Act 2005. Staff need to be aware of this and of their role and responsibility in supporting people who may not be able to make choices for themselves because they no longer have the mental capacity to do so. During this inspection we had the opportunity to have lunch with some of the people living here. The food was tasty, fish, chips and mushy peas. People said “there is always lovely food, if you don’t like it they make you something else”, “yes there is a choice but I like whatever they bring me to be honest”. “we’ve had a new cooker so I’m expecting some fine cakes to be baked soon”. People can choose where they want to eat their meals, they can have meals in the privacy of their own rooms, the dining room or in the lounge area with a tray table. We saw people being helped during mealtimes, staff did this sensitively and did not rush they people they were helping. Mealtimes appeared to be a relaxing event for the people who live here. The home has also recently been awarded a four star rating by the local environmental health department for meal preparation and planning. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. People’s views will be listened to and acted upon by this home. There are also good systems in place to protect people from harm. Further staff training would add to this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home displays the complaints procedure in the hallway at the entrance. There is also a home policy that needs to be updated. The policy review should give clear timescales for responding to complaints and who will be conducting the investigation in people’s concerns. Since our last inspection of this service there have been no complaints made. We, the commission, have not received any complaints about this service. There are systems in place for the reporting of allegations of abuse or poor practice. No referrals to the safeguarding vulnerable adults team have been made since our last visit. When we spoke to staff they were able to give us some information about the different types of abuse people may experience and also of the actions they would take to protect the people living in the home. Refresher training for staff is now due. The manager has this order and has already arranged for this to happen. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 16 We looked at the recruitment records for three new members of staff. It was pleasing to see that the home is completing all of the required safety checks before people begin working in the home. These checks include the Protection of Vulnerable Adults (PoVA) list and a Criminal Records Bureau disclosure (CRB). Both of these checks will help prevent unsuitable people from working in the home. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. The home is well maintained and offers a welcoming and comfortable place for people to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A brief tour of the home was undertaken. The home feels cosy and welcoming. There are communal lounges for people to use if they wish to. Lounges have a good range of seating for people to use. Individual bedrooms are generally spacious and decorated, as people want them. The rooms we saw had been personalised with photographs and furniture people had bought with them from home. We looked at maintenance records and found that equipment and facilities are being serviced regularly and kept in sound working order. A recent visit by the fire office has recommended that some of the current doors in use may not Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 18 meet current fire regulations. The home has addressed this by using fire retardant skins on these doors. This means that people now have the protection of adequate fire doors in the event of a fire. Additional security measures have also been taken by installing new external doors and alarms systems. The manager told us that she is still waiting to convert one of the unused toilets into a wet room for people to use. At present there are only showering facilities in the en suite rooms of two service users. An added shower would give people more choice and in some cases improved accessibility. Staff told us “not everyone likes a bath but they would like a shower, they can’t at the moment”. We also looked at the provision of bed rails and pressure relieving mattresses, we found one person’s bed rails and pressure mattress may not be compatible with one another and pose an added risk to the person using this equipment. The manager told us the home was in the process of replacing bed rails with new one that would all be compatible with beds. It is recommended that consideration should also be given to the replacement of some of the older beds in use for newer profiling beds for people’s added comfort. We have also recommended every person who uses bed rails should have them checked to make sure they are fitted correctly and do not pose any added risk to service users. Redecoration of the home is ongoing. We do not have any details from the provider about the programme of refurbishment or redecoration. This information would normally be provided in the AQAA. Infection control practices are generally good. There are hand-washing facilities in all toilets and bathrooms with liquid soap and paper towels provided. Staff report they have enough gloves and aprons to practice safely and reduce the risks of cross infection for people. The home has laundry facilities in place that have sluice disinfection cycles on washing machines. This will again provide another method of reducing risk of infection for service users. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. People’s needs are being met but staffing levels must be kept under review to reflect changes in people’s conditions. Staff are being recruited safely and the home is safeguarding people by doing this. Improvements in record keeping are needed so that the home has accurate details of staff training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels in the home will need to be reviewed. At present there are a lot of people in the home who are very dependent and need more intensive care. staffing levels have not changed to reflect this. Staff said “just one more person on a shift would make all the difference”. There are usually four care staff and one nurse on a morning shift and three carers and a nurse in the afternoon. However one of the carers from the afternoon shift is expected to help out in the kitchen with people’s teas. This means that the number of staff available to provide care for people is temporarily reduced and must be reviewed. We do not have the information about the National Vocational Qualification (NVQ) status of all the care staff in the home. This information is usually given to us by the home in the AQAA but we have not received it. We did speak to some of the staff that told us they have been supported through their NVQ’s by Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 20 the home. They said “yes I did mine although I feel I have learnt more from the home and experience after it”. We looked at the recruitment records of three new starters. All the files held the required information. We have made a recommendation about recruitment of trained nurses. The manager must make sure that she obtains confirmation from the Nursing and Midwifery Council (NMC) that nurses are fit to practice and have a current effective status. We examined induction records for new staff, some were incomplete but the current induction process could be further improved by making sure it meets the skills for care common induction standards. We have recommended the home consider this when reviewing the induction process for staff. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. The home is managed well but improvements are needed to ensure the home is run in the best interests of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Alison Wymark has now registered as a manager of the home with the commission. She understands the running of the home and is enthusiastic about the improvements that need to be made. The quality assurance system has been developed since the last inspection and the completion of the first report is now due. In order to do this the manager has sent survey out relatives and service users seeking their views of the service they receive. She intends to write to them individually thanking them Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 22 for their contribution in this process. In seeking people’s views about the home the manager can the plan to make improvements where needed to ensure the service is run in people’s best interests. The registered provider is also completing monthly unannounced visits as required by the care home regulations 2001. These visits give the provider the opportunity to meet with the people using the service and obtain their views on what it is like living in the home. We have requested the home send to us their Annual Quality Assurance Assessment (AQAA) this has not been done. This document gives the commission information about the service, how it has developed over the last twelve months, what it does well as a service and its plans for improvement. We have sent a reminder letter and Statutory Requirement Notice to the provider asking them to send us this information. We have still not received this and we are currently considering further enforcement action at this time. During this inspection we saw a half completed AQAA faxed to the home but the completed document has still not been sent to the commission. People are encouraged to manage their own finances in this home. The manager told us “we don’t hold any money for people but they do have lockable spaces in their rooms”. Health and safety systems are in place. The safety certificates for the maintenance of the home and equipment in it are up to date. The home uses bed rails to keep people safe whilst in bed, they do not use risk assessments however. We have said this must happen to reduce the risk to the people using bed rails. There is a rolling programme for staff training in mandatory subjects such as food hygiene, moving and handling, infection control and first aid. The manager has also taken steps to arrange further fire training for staff with the local fire officer. Fire records were seen and found to be in order. The home records fire drills, checks on fire equipment and fire alarms. Bramshall`s Old Rectory DS0000059275.V366286.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 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement People must have a plan of care at the point of admission to the home. This will make sure their needs are known and met by the home. People’s care plans must be kept under review, this must be done at least monthly and when people’s condition changes. People must be weighed regularly and actions taken to address weight loss must be recorded. The home must make sure that the temperature of the treatment room and the fridge is recorded on a daily basis. This will ensure that medication is stored as per manufacturers instructions. Staff must record the variable dose given to people when signing the MAR sheet Handwritten MAR must have all the information needed to instruct staff when administering medication. This will reduce the risk of error to people using the service. DS0000059275.V366286.R01.S.doc Timescale for action 30/07/08 2 OP7 15 30/07/08 3 OP8 13 (4) 30/07/08 4 OP9 13(2) 30/07/08 5 6 OP9 OP9 13(2) 13(2) 30/07/08 30/07/08 Bramshall`s Old Rectory Version 5.2 Page 25 7 OP33 24 (2) The home must provide the commission with their Annual Quality Assurance Assessment when it is requested. (extended timescale of 31/05/08 not met) 13/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 Refer to Standard OP1 OP2 OP7 OP8 OP8 OP9 OP14 OP27 OP38 Good Practice Recommendations Clear information about the range of fees the home charge should be included in the Service User Guide for people’s information. Each person admitted to the home should have a contract/terms and conditions given to them at the point of admission. It is recommended that self-funding residents have review 6 weeks after placement to ensure an equal service with funded residents. The home should introduce a fall risk assessment so that it can identify those people at risk and enable them to take preventative action where needed. The home should introduce an nutritional screening tool so that they can identify people at risk earlier and take preventative action where needed. A larger medication trolley is needed to adequately transport medication around the home. Staff should have training so that they understand the principles of the Mental Capacity Act 2005 and their role in supporting people Staffing numbers should be reviewed and changes made to reflect the changing needs of the people using the service. Records of building & equipment maintenance should be kept in the home. Bramshall`s Old Rectory DS0000059275.V366286.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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