CARE HOMES FOR OLDER PEOPLE
Bramshall`s Old Rectory Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST15 5BQ Lead Inspector
Mr David Cowser Key Unannounced Key Inspection 2 November 2006 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.V316597.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.V316597.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bramshall`s Old Rectory Address Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST15 5BQ 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.V316597.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. PD minimum age 60 Years Date of last inspection 4th January 2006 Brief Description of the Service: Bramshalls 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 (3 beds). The home is situated in the village of Bramshall with good road access to Uttoxeter, some three miles away, in delightful country surroundings. Delightful views are afforded over the rolling Staffordshire countryside. The original buildings have been extended, and lifts and stairs access the three floors. A homely environment has been created throughout. Hotel services and facilities including bathrooms, laundry and catering are adequate. 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. Registered nurses and care assistants led by an Acting Care Manager, who is a first level nurse, deliver care. Registration of care manager must be undertaken. 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 be involved with the home. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection was made on the 2 November 2006 @ 08:30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 11hrs. The acting care manager (RGN) was in charge of the home accompanied by two first level registered nurses and six care assistants. The ancillary staff on duty included; 2 domestic workers, laundry worker, maintenance person, and 2 catering staff. These staffing levels were adequate to meet the needs of the current 26 service users in the home. The total of 26 residents included; 18 people receiving nursing care for physical needs, and 8 receiving personal care for needs associate with old age. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with eight residents and four visitors, discussions with staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 4 January 2006 there had been a change to the care management of the home (see Std 31). An application must now be submitted to CSCI for the registration of care Manager. No additional visits had been necessitated by CSCI. Residents and visitors made positive comments about the home, including; ‘I am very happy here and have no complaints’. ‘I am well satisfied with the home’. ‘The staff will do anything for you, and its never too much trouble’. ‘My mother is being well care for and staff are very caring’. Current fees range from; £352 to £460 per week. What the service does well:
Residents and/or their representatives had been able to choose the home, following an assessment undertaken by the nursing staff and an invitation to visit, prior to admission. Asking four residents and four visitors, and inspecting the admission documentation, confirmed this. The above aspects had assisted in ensuring that each resident had been suitably placed, and that the home had the ability to meet their assessed needs. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 6 It was evident, from discussions with residents and staff, and an inspection of the relevant documentation, that the provision of health and social care had been addressed well. Service user plans seen had been completed and regularly reviewed. The plans were based on the community care plans completed by social workers, and agreed by residents/representatives. There was a safe system in place for the receipt, storage, administration and disposal of medicines. No errors were noted concerning medicines, and residents asked said that they had their right medicines on time. Privacy, dignity and choice aspects for residents were seen being upheld during the caring process. When asked several residents and relatives said that they were very happy with the health and personal care being delivered by the home. During the past 12 months the number of accidents and incidents in the home was low. Activities and entertainment, arranged by the activities organizer, had taken place and were seen documented. Residents told the inspector that they had appreciated and enjoyed the recent events and activities, and that they were able to choose whether or not to take part. Four visitors confirmed that links had been maintained with them and links had also been maintained with the local community. Catering aspects were good and records seen showed that individual dietary requirements had been met. Residents spoke of choices and said that they were generally pleased with the food provided. The inspector observed the main meal of the day, which met all requirements and was well presented. Assistance was seen being given to people with mental health or dementia care needs to help them to make a choice, by staff who had knowledge of the residents likes and dislikes. All of the above had assisted the residents in their daily living and social activities. There was a system in place for the reporting of incidents or reports of abuse of any kind, and policies and procedures seen covered these issues. No complaints had been received by CSCI or recorded in the home. Residents and relatives understood the complaints procedure. These aspects had contributed to the protection of service users. The home was fit for purpose, and provided a safe and secure environment for the residents, staff and visitors. A homely atmosphere had been created and the premised were very clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities including catering and laundry were adequately provided, and staffed. All residents asked stated that they were happy with the facilities and that they were comfortable with their surroundings. The acting care manager and teams of nurses and care staff provided care. An application must now be submitted to CSCI for the registration of care manager. A good working relationship was evident with the local GPs, who were also pharmaceutical dispensing practices. NHS facilities and both community and hospital health professionals had been accessed when required. Community Psychiatric Nurses were also accessed to meet the mental health needs of service users. Staffing levels and skill mix had been
Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 7 adequate to meet the assessed needs of the existing residents. Recruitment of staff and employment aspects was good. Staff training had been given a high priority, with induction training being followed by NVQ training. In addition to the trained nurses 67 of care assistants were qualified to NVQ level 2 or above. NVQ training and in house training in relevant subjects is on going. These aspects had contributed to the good standards of care being provided by the home. The acting care manager is experienced and is backed by a deputy. The general management, and management of health and safety issues had been addressed. The documentation seen evidenced that the premises were adequately maintained (see also requirements). All records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures were adopted. The current public liability insurance certificate was seen. There was a safe system of accounting for residents day to day monies/expenditure. Quality assurance systems are in place. All the above had contributed to the protection and well being of residents in the home. Throughout the inspection the people who use, or have contact with, the home expressed only positive views. A folder containing thank you cards and complimentary letters from appreciative relatives was seen. What has improved since the last inspection? What they could do better:
Three requirements were made against the Regulations: 1. The defective vinyl floor covering in the corridor and kitchen areas identified must be replaced or made safe, as agreed. 2. The requirements of the Environmental Health officer’s letter dated 3 February 2006 must be complied with, as agreed. 3. An application must be received by CSCI, for the proposed care manager, to enable the registration process to commence. Five recommendations were made against the National Minimum Standards: 1. The acting care manager should embark on NVQ level4 management studies, as agreed.
Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 8 2. The main kitchen should be deep cleaned, and ongoing cleanliness should be maintained. 3. The redecoration programme should continue with priority given to the bathrooms and bedrooms identified. It is understood that the kitchenette and main kitchen areas will also be included. 4. The grounds and gardens should be given attention e.g. grass cutting, tidying, moss removal, all as agreed. 5. The records of building and equipment maintenance items that have been completed should be available for inspection in the home (currently at headquarters), as agreed. It is understood from a discussion with the acting Care Manager that the above issues will be addressed in the agreed timescales. See end of report. 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.V316597.R01.S.doc Version 5.2 Page 9 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.V316597.R01.S.doc Version 5.2 Page 10 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): Standards 3,6. The quality outcome for the above standards, based on this inspection and available evidence is good. Residents have been correctly placed in a home of their choice, which has the ability to meet their assessed needs. Intermediate care was not undertaken in this home. EVIDENCE: The documentation seen, and a discussion with both residents and their representatives, evidenced that residents had been assessed prior to admission and they had been able to make a choice about the home. All had been given the opportunity to visit the home prior to choosing to stay. Two residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. A full assessment of each resident’s needs had taken place before admission and this was seen documented. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user
Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 11 plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments. Intermediate care was not undertaken in this home. All of the above had contributed to suitable placements and the residents needs being met. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10 The quality outcome for the above standards, based on this inspection and available evidence is good. Individual health, personal and social care needs, as documented within care plans, had been adequately addressed with privacy and dignity afforded during the caring process. There was a safe system in operation for the receipt, storage, administration and disposal of medicines. NHS health care facilities and professionals had been accessed when required. Particularly attention had been paid to meeting mental health and dementia related needs. EVIDENCE: The service user plans and associated documentation seen was well written, meaningful and reflected the current condition of residents. The care plans seen and the associated documentation, and a discussion with both residents and staff members, evidenced that health and personal care needs were being met. A total of 4 care plans were examined in greater depth. The dementia/mental illness related needs of residents had been documented when applicable, and staff training had been provided covering these issues.
Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 13 NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A good working relationship had been established with community nurses and the community mental health team, and the documentation seen evidenced this. Local GP practices that also dispense medicines service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. Currently there are two residents receiving care for tissue viability, and these aspects are being dealt with and recorded. The clinical nurse specialist for wound care is also consulted as and when required. The medicines within the home, medication administration records, controlled drugs books and drugs disposal books, were all checked and no errors were noted. The documentation seen evidenced that only trained nurses administered medicines. No resident was ‘self medicating’, but locked facilities were available throughout. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. Several residents told the inspector that they were treated with respect, and that the staff were very kind. Residents, and several relatives, all commented positively about the care being provided. There had been only 4 deaths in the home during the previous 12 months, which is low in view of the numbers of poorly nursing patients admitted over this period. All of the above evidence satisfied the inspector that the individual health, personal and social care needs of residents had been addressed in the correct manner. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 14 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): The quality outcome for all the above standards, based on available evidence and this inspection is good. Social contact had been maintained and the daily activities, along with autonomy and choice, had contributed to the resident’s lifestyle experiences meeting their expectations. Catering aspects were good and met individual needs and preferences. EVIDENCE: The residents asked told the inspector that their views had been listened to, and that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus. These comments had been documented along with the feed back from the resident/relatives questionnaires and they had been acted upon. Contacts had been maintained with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. Visitors reply cards emphasized the good links, communication and the homes involvement with them. Trips out to the community had been arranged and transport provided, but most had declined. The activities organiser had coordinated and recorded the events that had taken place, and residents commented that these had been appreciated. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 15 The residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met. A discussion evidenced that individual likes and dislikes had been established and complied with. The cook had established resident’s choice of food for the day. The records evidenced that residents’ needs with diabetes had been met. The cook when asked said that fresh good quality food from local suppliers was purchased on a daily/weekly basis, the records seen confirmed this. Adequate supplies of fresh vegetables and fruit were also seen. The mid day meal seen was well presented and met all nutritional requirements. The meals were seen being served in a caring and unhurried manner. All of the above had contributed to the satisfaction expressed by service users/representatives during the inspection. Bramshall`s Old Rectory DS0000059275.V316597.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): Standards 16,18 The quality outcome for the above standards, based on available evidence and this inspection is good. An open culture existed where complaints or grumbles are listened to and acted upon. Residents are protected from all forms of abuse. EVIDENCE: An examination of the complaints records, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with. No complaint had been received by CSCI since the last inspection, or recorded in the home. No additional visit had been necessitated to the home by CSCI. From a discussion with residents and visitors it was evident that they knew how to make a complaint if they needed to. A folder was seen with ‘thank you’ and complimentary cards from appreciative relatives. The policy documentation seen, and a discussion with staff and management on the day of this inspection confirmed that residents are protected from all forms of abuse, and that correct procedures are in place to deal with any issues raised. Documentation seen also evidenced that these issues had been discussed during staff induction, training and on-going supervision. Bramshall`s Old Rectory DS0000059275.V316597.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): Standards 19,26 The quality outcome for the above standards, based on available evidence and this inspection was adequate. The home was generally clean, pleasant and hygienic, and provided a suitable and safe environment for the provision of care. Exceptions are identified below. EVIDENCE: A tour of the building, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The senior staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The laundry and sluicing facilities were seen to be compliant. The main kitchen should be deep cleaned, and ongoing cleanliness should be maintained. The redecoration programme should continue with priority given to the bathrooms and bedrooms identified. It is understood that the kitchenette and main kitchen areas will also be included. The grounds and
Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 18 gardens should be given attention e.g. grass cutting, tidying, moss removal, all as agreed. The records evidenced that the premises were being maintained (see also Std 38). Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Fire Prevention. The requirements of the Environmental Health officer’s letter dated 3 February 2006 must be complied with, as agreed. Some of the bedrooms and communal spaces seen were decorated well and a homely atmosphere was observed. Residents asked expressed satisfaction with the environment, and had made their rooms comfortable. All of the above had contributed to the comfort and protection of people using the service. Bramshall`s Old Rectory DS0000059275.V316597.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): Standards 27,28,29,30 The quality outcome for the above standards, based on available evidence and this inspection is good. Adequate numbers of suitably trained and experienced staff are correctly employed to meet the assessed needs of residents. EVIDENCE: The acting care manager (RGN) was in charge of the home accompanied by two first level registered nurses and six care assistants. The ancillary staff on duty included; 2 domestic workers, laundry worker, maintenance person, and 2 catering staff. These staffing levels were adequate to meet the needs of the current 26 service users in the home. The duty rosters seen and a discussion with the manager and the staff evidenced that adequate numbers of nursing and care staff had been on duty to meet the needs of the existing service users. An examination of the rosters evidenced that in addition to the registered care manager, the following care staff had been maintained or exceeded for the 24 residents: Morning Afternoon –1 RGN 5 care assistants –1 RGN 4 care assistants Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 20 Night time –1 RGN 2 care assistant (awake on duty) Manager on Call These levels are adequate to meet the needs of the current service users. In addition to the above adequate ancillary staff were rostered on duty throughout the week. Several residents asked stated that care staff were available when they wanted them, and that the staff were capable. The records seen evidenced that, in addition to the trained nurses, 21 care assistants were employed, of which 14 (67 ) were trained to NVQ level 2 or above. NVQ training is continuing with care staff taking level 3. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Training had been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they had been afforded the time off and encouraged to study. The records seen and a discussion with the staff evidenced that, individually and collectively, they had the necessary experience and skills to meet the assessed needs of the current service users. Bramshall`s Old Rectory DS0000059275.V316597.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): Standards 31,33,35,38 The quality outcome for the above standards, based on available evidence and this inspection is adequate. An experienced acting care manager is managing the home in the best interests of service users and in an open an inclusive atmosphere. The home is on a sound financial footing and has safeguards for the health and well being of residents’ staff and visitors. The registration of the acting care manager and the resolution of a health and safety issue must be addressed. EVIDENCE: The acting care manager is well experienced, and supported by a deputy. An application must be received by CSCI for the proposed care manager, to enable the registration process to commence. The acting care manager should also embark on NVQ level 4 management studies, as agreed. An open,
Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 22 positive and inclusive atmosphere was observed during the visit and confirmed to the inspector by service users and relatives. Records and record keeping was in order with good systems in place. From observations made, discussions with service users and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. Staff supervision sessions, six times per year, had all been completed and documented. A check on the records and a discussion with both residents and relatives evidenced that all service users had the opportunity to handle their own finances, and residents and families had chosen to do so. The system for resident’s day-to-day expenditure worked well and invoices, seen as correct, were raised. Inventories of valuables and belongings brought into the home were seen recorded. One health and safety issue was noted during this inspection, including a tour of the home; the defective vinyl floor covering in the corridor and kitchen areas identified must be replaced or made safe, as agreed. The documentation seen for checks and examination of plant and equipment was correct and up to date. The records of the remaining building and equipment maintenance items that have been completed were not available for inspection in the home (currently at headquarters). The home owner had previously given assurances that the home is financially viable and that they adopt suitable accountancy and budgeting procedures. The current public liability insurance certificate was seen up to date and correct. All of the above aspects had contributed to the safety and well being of service users, staff and visitors. Bramshall`s Old Rectory DS0000059275.V316597.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 X X 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 2 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Bramshall`s Old Rectory DS0000059275.V316597.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 OP38 Regulation 13(4)(a) Requirement The defective vinyl floor covering in the corridor and kitchen areas identified must be replaced or made safe, as agreed. The requirements of the Environmental Health officer’s letter dated 3 February 2006 must be complied with, as agreed. An application must be received by CSCI, for the proposed care manager, to enable the registration process to commence. Timescale for action 02/12/06 2 OP19 16(2)(g) 02/12/06 3 OP31 8&9 02/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The main kitchen should be deep cleaned, and ongoing cleanliness should be maintained. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 25 2 OP19 3 4 5 OP19 OP31 OP38 The redecoration programme should continue with priority given to the bathrooms and bedrooms identified. It is understood that the kitchenette and main kitchen areas will also be included. The grounds and gardens should be given attention e.g. grass cutting, tidying, moss removal, all as agreed. The acting care manager should embark on NVQ level4 management studies, as agreed. The records of building and equipment maintenance items that have been completed should be available for inspection in the home (currently at headquarters), as agreed. Bramshall`s Old Rectory DS0000059275.V316597.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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
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