Inspection on 30/07/07 for Bramshall`s Old Rectory

This inspection was carried out on 30th July 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

Bramshall`s Old Rectory 13/06/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bramshall`s Old Rectory Leigh Lane Bramshall Nr Uttoxeter Staffordshire ST14 5DN Lead Inspector Peter Dawson Unannounced Inspection 30th July 2007 09:00 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.V338481.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.V338481.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 vacant post 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.V338481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD minimum age 60 Years Date of last inspection 2nd November 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. 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 an Acting Care 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. Bramshall`s Old Rectory DS0000059275.V338481.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 carried out by one inspector on one day from 9am. – 4.30pm. The National Minimum Standards for Older People was the reference used. The service did not return an Annual Quality Assurance Assessment to CSCI prior to the inspection. This is a requirement under the Care Home Regulations and must be completed on each occasion requested in future. There was, therefore no direct written input into the inspection by the home. The Acting Registered Manager was present throughout the inspection and she and all staff engaged positively making a valuable contribution to the inspection process. The majority of residents were seen and many spoken with throughout the day. All made very positive comments about the care provided, staff and daily life in the home, there were no negative comments or any areas of concern, although they were encouraged to express their views. Several visitors were seen also and similarly made positive comments about the service – the standards of care and staff attitudes. Residents, visitors and observations indicated that a very relaxed atmosphere was always present in the home with friendly and affectionate exchanges between staff, residents and visitors. High standards of health and personal care were evidenced in discussions and also in care planning information. Current fees charged at The Old Rectory are from £395 - £485 per week. What the service does well: Pleasant and pleasing environment with good facilities. Mainly single bedrooms many with exceptional views of the surrounding countryside. External areas including the rolling lawns to the rear provide a country-house appeal. It was interesting to note that the large display of summer flowerpots and hand-painted stones at the entrance to the building had been planted and painted by residents demonstrating interest, occupation and ownership. A relaxed homely atmosphere confirmed in discussions with residents and visitors. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 6 Staff are well trained and have a positive approach to health care needs with referrals to other healthcare professionals where appropriate. A record of good assessments relating to tissue viability issues with good wound-care management evidenced by the low incidence of pressure ulcers and swift improvements in other areas of wound-care inspected. Chosen lifestyles are at the centre of the homes philosophy, this was confirmed in discussions with residents and visitors and from observations. What has improved since the last inspection? What they could do better: Application must be made to CSCI to register a manager. The Acting Manager should source an appropriate course for the required management qualification. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 7 The Responsible Individual must provide written reports for the Manager which must be left in the home following the monthly unannounced visits. Health care declarations must be completed by all applicants for employment. Some areas of medication could be improved by means of a count of medication, stricter recording of medication to be disposed of and medicated creams should be in a locked facility. Provision of a larger, more appropriate medication trolley would assist in the administration of medication for up to 30 people. It is recommended that self-funding residents have the same opportunity as funded residents by arranging a review of placement after 6 weeks. It is important that all residents are weighed regularly. Records of maintenance for the building and equipment should be available in the home for inspection. 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.V338481.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.V338481.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): Quality in this outcome area is good. There is adequate information to enable choice of home. Assessments are made prior to admission and provide the basis for care plans. There is open visiting for prospective residents and their families. All residents are provided with written contracts. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a statement of purpose/service users guide in place and available to enable prospective residents to make a choice about the home. Documentation seen in three records sampled for recently admitted residents showed that the home had carried out a needs assessment prior to admission and included all required information under Standard 3. In two of the three sampled there was also a Care Management Assessment obtained prior to Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 10 admission. In one instance where this had not been obtained the person was self-funding and a comprehensive assessment had been carried out by the home. The assessments provided the basis for care planning information. The Acting Manager was advised to provide information in writing to all people assessed that the home is able to meet their needs in respect of their health and welfare as defined in Regulation 14. Residents were provided with contracts from the local authority, or in the case of self-funding residents - by the home. Bramshall`s Old Rectory DS0000059275.V338481.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): Quality in this outcome area is good Care plans are good. Health, personal and social care needs are clearly set out. Staff are pro-active about health care and needs are fully met. Some areas of medication should be clarified and strengthened. Service users are treated with respect and privacy upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of 4 care plans were inspected relating to recently admitted and also long-term residents. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 12 Assessments carried out had provided the basis for detailed care plans. The care planning format was impressive giving clear but detailed information on the actions to be taken by staff to meet need. Care plans contained information concerning the health and social care needs of residents. Where specific health care needs were identified a care plan was established outlining the actions to be taken - examples were high waterlow scores, tissue viability and wound care inputs etc. All were regularly reviewed on a monthly basis. There was very detailed information about routines and choices, including likes/dislikes and included detail such as “likes a whiskey at night” to “2 pillows set at angles” etc. Daily notes seen were recorded for each of the 3 daily shifts and contained concise and relevant information to monitor progress. The care planning information was to a good standard and reviewed regularly. Monthly observations of all residents were recorded including temperature, blood pressure, pulse and weight – all were completed except weights and this should be included as an important part of monitoring health and well-being. The home has a good record of tissue viability practice. At this time only one resident has a small skin break, evident in hospital prior to admission and being treated and contained. There is a detailed care plan in place to address this. The home has 6 pressure relieving mattresses (airwave) and pressure relieving cushions readily a available These are allocated on waterlow/nutritional risk assessments. Preventive actions, very close monitoring and high staff awareness contribute to the homes success in this area of work. This is an area of work constantly changing and the Acting Manager is presently looking for professional training to update present skills – courses are not easy to locate. The home has implemented the Liverpool Pathway for ensuring the highest standards of palliative care in residents final days of life. There has been staff training in this area by the Palliative Care Specialist Nurse and one member of nursing staff completed ENB 931 (specialist qualification) in palliative care. None of the residents presently fall into this category but it has ensured a smooth and seamless service for 2 residents formerly diagnosed. The home has worked hard in forming the necessary professional working relationships with other healthcare professionals. The medication system was inspected. The home continues to use the bottle to person method (monitored dose system not available through the GP/Pharmacy link). The medication trolley is small and inadequate for its purpose – to administer medication to up to 30 people. Because of lack of Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 13 space an additional locked container (for residents in bedrooms 1 –6) has to supplement the trolley and be taken simultaneously around the home. This is not satisfactory and a larger replacement medication trolley is recommended. The MAR (medication administration records) were accurately completed and there were no gaps of signature. The number of tablets were not recorded on MAR sheets, so it was not possible to check and audit the system. Numbers of tablets at the beginning and end of the medication cycle are required to ensure numbers in stock can be authenticated at any point in the cycle. Surplus medication is disposed of in bins from the waste contractor, but no record made of which medication is disposed of. To ensure safe and viable disposal it is recommended that the date, number and type of medication is recorded and signed by staff when placed for disposal. This will complete the medication audit trail. There were some discrepancies between prescription labels on medication and entries on MAR sheets which need to be resolved with the pharmacy/GP these included - medication labelled “as directed” and entered on MAR sheet as PRN. In another instance Dusolepin was labelled “2 at night” but given at 9am and 9pm. Bramshall`s Old Rectory DS0000059275.V338481.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): Quality in this outcome area is good. Chosen lifestyles are accommodated and residents satisfied with the social and recreational activities that satisfy their needs. There are strong ties with family/friends/visitors both residents and staff engaging positively together with residents. Residents said that their individual choices were known and met. There is a high level of satisfaction with the food provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preferred lifestyles and choices are recorded in care plans and residents in discussion confirmed that their preferences were known and their chosen lifestyles known and met. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 15 Several residents spend considerable time in their bedrooms as they wish and receive visitors there, some have meals served in their bedrooms other spend time in the rooms and come to the dining room for meals. One person resident for 6 months spends all her time in her bedroom for health reasons and from choice. She has meals delivered there, she has her own daily routines and receives visitors. She said that she was entirely happy with the care and service provided to her and her chosen lifestyle is accommodated. The home have an Activities Co-ordinator who works 10 – 1 pm over 5 days. She organises a range of activities within the home with a daily programme of events from bingo to painting, her enthusiasm is infectious and residents said that they enjoyed the stimulation and pleasure derived from the activities. A recently admitted man with high dependency needs has responded very positively to the activities he has become involved - in much to the surprise of his family/visitors. Activities are provided for all residents including those who spend time in their bedrooms when 1:1 time is spent with them. Entertainers are brought into the home several times each month and several residents said they enjoyed those occasions immensely. Pastoral care needs are met with regular monthly visits from Roman Catholic and Church of England clergy, there are no other religious needs identified at this time. Visitors were seen to arrive/depart during the day of inspection, engaging in a warm and positive way with staff and other residents. A man visits his wife daily and has lunch with her in the lounge area which they both enjoy, he also attends for the entertainment he enjoys also. A relative of a person who has had respite care previously spoke highly of the care and individual care offered to her relative. She has now decided to book a room permanently, spending time between her own home and the Old Rectory at times when she needs greater support. This is an excellent arrangement for her allowing her to remain at home in the community for as long as possible. Food provision is to a very high standard. Menus were seen providing a varied, interesting and balanced diet. Fresh produce is delivered from local suppliers on a daily basis. The cook bakes puddings and cakes for tea each day. She is totally committed to her work, her objectives being to provide food residents enjoy and are able to comment upon. Residents spoken to said food satisfaction was high for them, they were consulted about their preferences and entirely happy with the food provided for them. The cook consults them on a daily basis. Bramshall`s Old Rectory DS0000059275.V338481.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. Procedures are in place and known to residents for making complaints about the service. Protection procedures, staff training and awareness ensure that residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure posted in the home for residents and visitors, there is a copy with the service users guide also. There is also a compliments folder recording satisfaction with the service. Two residents said that they were aware of the procedure for making complaints and that they would feel comfortable in raising any areas of concern. No complaints have been received by the home or the Commission in the past year. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 17 There is a policy document, available to staff in relation to protection of residents. There was evidence that protection issues were discussed during staff induction, training and supervision. Bramshall`s Old Rectory DS0000059275.V338481.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. A well presented environment which is safe and well-maintained and provides a comfortable homely feel. There are adequate services and equipment to cater for the needs of all residents. Bedrooms are attractive, pleasant, well personalised and suit the needs of residents Standards of hygiene throughout are high. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 19 Requirements/recommendations were made in the last report relating to the environment – all have been addressed as follows: The defective vinyl flooring in the corridor and kitchen areas has been replaced improving appearance and infection control. There is now a cleaning schedule in place to ensure the kitchen is cleaned regularly and to required standards. Bathroom and bedrooms have been redecorated improving presentation, part of the kitchen area has been redecorated, completion of the main area is planned. The grounds and gardens have been given required attention, a gardener is now employed 4 hours per week – the grounds looked well-kept and attractive. All requirements in the Environmental Health Officers report dated 3.2.06 have been addressed – there has been a subsequent visit by the EHO (letter seen) and all matters raised resolved. At the time of the inspection a bedroom was being re-decorated awaiting new resident. Some bedrooms have been redecorated, carpeted and refurnished after vacation by some long-term residents who had not been disturbed for this purpose due to illness etc. There are 4 bathrooms 3 have assisted facilities, two have been redecorated. One bathroom on the ground floor is the one mainly used and reportedly preferred by residents - it has a good assisted facility There are plans to upgrade one of the bathrooms with an inappropriate type shower facility. Twelve bedrooms have en-suite facilities, some have bathrooms which are not appropriate/useable. There are plans to possibly increase the number of ensuite facilities. A large gap was noticed under the rear entrance door and this will be dealt with. The environment presented well with 2 large lounge areas and separate dining area. Residents clearly made choices about where they sat/spent time. The large lounge was well populated with activities taken place, the smaller lounge (no TV) was a quieter area providing a choice. Both lounges were bright, pleasant, well furnished and comfortable with extensive views over the surrounding countryside from this large country house on the edge of a small village. A sample of bedrooms seen were similarly well furnished and equipped, clean and comfortable. Those seen had considerable personalisation reflecting the lives and individuality of residents, most had the delightful views mentioned above. There are 2 shared bedrooms but they are used as single rooms unless someone specifically asks to share and both people consent. Bramshall`s Old Rectory DS0000059275.V338481.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. Adequate numbers of well-trained staff ensure residents needs can be met. Recruitment procedures are adequate, health care declarations are required. A competent cohesive staff group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels of the home remain the same and are satisfactory. The number of care staff on duty throughout the 24 hour period is 6:5:3 – this includes one nurse on duty throughout the 24 hour period. Additionally the Manager is on duty (but not the rota) throughout the week. There are adequate numbers of support staff for activities, catering, laundry, domestic, maintenance, gardening and administration purposes. Many staff have been employed for several years and staff changes are few. Staff seen and spoken with showed enthusiasm, commitment and pride in their work and their varied duties. Dialogue observed there were no barriers across the different staff groups, all worked together – one residents said “I have never heard any negative comments made by staff about each other or anyone Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 21 else” There was an excellent rapport between residents, staff and visitors observed throughout the inspection. A member of staff on maternity leave brought the new baby who was introduced to all staff and all residents the impression was of a large family group engaging together. A sample of 3 staff files were seen and documents required under Schedule 2 were in place with one exception – there were no health care declarations. These must be provided for all new staff as proof that the person is physically and mentally fit for the purpose of working in the home. CRB checks had been obtained in all instances prior to employment. Training has had a high priority – all statutory and professional training has been made available to all staff. 70 of care staff have received NVQ training. Bramshall`s Old Rectory DS0000059275.V338481.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 adequate The Acting Manager shows competence in managing the home but application must be made swiftly to CSCI for approval of a Registered Manager The provider must provide written records of monthly visits to the home. Staff are well-supervised with policies/procedures to support them. Maintenance records must be available in the home to ensure residents are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 23 There is an Acting Manager, a registered nurse, who has been at the home for over 12 months, she shows competence and leadership in managing the home, but she has not been approved by CSCI as the Registered Manager. A requirement was made at the time of the last inspection that an application must be received by CSCI by 02/12/06 for a proposed Registered Manager – this has not been done and is further repeated as a requirement of this report. There was also a recommendation that the Acting Manager embarked upon an NVQ level 4 course in management studies but this has not yet been accessed. It was reported that the Responsible Individual/Registered Provider visits the home on a monthly basis, but here is no record or report of those visits. Compliance with Regulation 26 is required - A responsible individual is required to visit the home unannounced on a monthly basis and after inspection of the home and discussions with residents and staff, must prepare a written report on the conduct of the home which must be supplied to the manager and available in the home for inspection. A recommendation of the last report was to ensure that maintenance records of the building and equipment should be available in the home. This has not been done. It was therefore not possible to check the servicing and maintenance of equipment. Records are apparently at the homes HQ in London. These must be made available in the home for inspection. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 24 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 3 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 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X X 3 3 2 Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Monthly count of medication should be recorded on MAR sheets to ensure an audit of the system. Stricter recording of the disposal of medication required. Health care declarations must be obtained from all new staff. Application must be made to appoint a Registered Manager – Previous timescale 2/12/06 not met A written report must be left in the home following monthly visits by the registered provider. Timescale for action 31/08/07 2. 3. OP29 OP31 Schedule 2(6) 8&9 31/08/07 31/08/07 4 OP32 26(4)(3) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP8 Good Practice Recommendations It is recommended that self-funding residents have review 6 weeks after placement to ensure an equal service with funded residents. Ensure all residents are weighed at least monthly DS0000059275.V338481.R01.S.doc Version 5.2 Page 26 Bramshall`s Old Rectory 3. 4. 5. OP9 OP9 OP38 Medicated creams must be stored securely either in lockable facility in bedrooms or clinical storage room. A larger medication trolley is needed to adequately transport medication around the home. Records of building & equipment maintenance should be kept in the home. Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House, 45-56 Stephenson Street Birmingham West Midlands B2 4UZ 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 Bramshall`s Old Rectory DS0000059275.V338481.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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