Inspection on 01/06/05 for Brandley Residential Home (Sunflower House)

This inspection was carried out on 1st June 2005.

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

Brandley Residential Home... 09/05/06

Brandley Residential Home... 11/11/05

Brandley Residential Home... 06/10/04

Brandley Residential Home... 03/06/04

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

CARE HOME ADULTS 18-65 Brandley Residential Home Sunflower House 102 Durham Road London E12 5AX Lead Inspector Anne Chamberlain Announced Inspection 1 June 2005 at 9.30 am st 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Brandley Residential Home Address Sunflower House, 102 Durham Road, Manor Park, London, E12 5AX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8478 6233 020 8478 6367 Mr Andrew Garner Ms Beverley Beaupierre Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th October 2004 Brief Description of the Service: Sunflower house is run by Brandley Residential Homes. It is a four bedroomed property in a residential road in the borough of Newham. The home is registered for three adults between the ages of 18 and 65. However variations have been obtained for service users who are now over 65 years. Service users have learning disability and related mental health issues. The home aims to offer quality care services in a well-kept homely, non institutionalised establishment. The ground floor has a good sized kitchen diner, reception room, toilet and shower room and laundry room. The office is located downstairs. There is also a small courtyard garden and a small garden beyond the laundry room. There are currently three service uers living at Sunflower house and they are supported by a total of six staff including the manager. There is a sleep in member of staff. Service users have access to day services and they are enabled to participate in community leisure activities. Service uers are supported and encouraged to be as independent as possible. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over one day and took eight and a half hours. The inspector viewed policies, documents, files and records, toured the premises, including the garden, and talked to three service users, although it should be noted that their verbal communication was rather limited. She interviewed the manager, deputy manager and spoke to the registered proprieter. The inspector would like to take this opportunity to thank the service users, manager and staff for their co-operation and assistance with the inspection. What the service does well: What has improved since the last inspection? The service users now in residence form a compatible group and their needs can be met within the expertise of the staff group. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 6 The home has met a number of requirements of the previous inspection in necessary improvements to the fabric of the property. The décor in the kitchen is now of a good standard and this is apreciated by service users. The home has improved its recruitment practice and recording of the same in staff files. Staff have approached the difficult subject of dying and death and had good initial discussions with service users. The manager has purchased consultancy for safe working practices and the organisation will benefit from this specialist assistance. What they could do better: The inspection resulted in six legal requirements and two recommendations. The home is very small with only three service users and the manager acknowledges that she struggles to meet the requirements of the various inspecting bodies, whilst still providing a homely and domestic atmosphere. She has been encouraged by the inspector to think laterally around the dilemmas which arise in this connection. The manager is not satisfied with the current documentation which has grown up over several years and is wishing to standardise and streamline the paperwork. The service needs to engage with the concept of assessment, care planning and review of care plan, accepting that the care plan needs to be updated regularly and eliminating duplication. Service user plans need to set goals which can be broken down into tasks and measured at review. They should give staff detailed information on how to provide care. This will benefit service users as there will be greater clarity for staff as to how to meet needs and more measureable outcomes. The manager acknowledges that because the service is small she has been used to carrying a lot of information in her head. She is committed to better recording and needs to decide on her information systems and implement them. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 4. The home has produced information which will help prospective service users make a decision about whether they would like to live there. The needs of prospective service users are thoroughly assessed before they are offered a placement. They are also given a opportunities to visit and meet other service users to help with the decision of whether to move in. EVIDENCE: The manager of the home acknowledged that the Statement of Purpose does not contain information regarding her qualifications and undertook to amend the document to show this. This is a restated requirement. Two new service users have been admitted since the last inspection. The needs of these service users had been fully assessed by the placing authority and also by the home manager, prior to admission. The manager was able to give the inspector full descriptions of the needs and social histories of both service users. Both the service users who have been recently admitted visited the home on more than one occasion, including overnight stays, before they decided to move in. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 10 Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9. The manager and staff undertake assessment and risk assessment. The service user plans don’t identify goals or advise staff the steps needed to meet them. The staff encourage service users to take decisions and support them to follow them through. EVIDENCE: There was much evidence on file of the assessment of service users needs. The inspector also viewed service user plans. The initial plan is usually devised by the placing social worker and is updated at the annual review. It was noted that the plans are broad and tend not to identify personal goals. It is recommended that the home further develop these plans to identify goals with service users. Please see standard 18. This is a recommendation. The service users at Sunflower house tend, as a group, to be rather passive, and the manager has identified this trait in the two new service users. However there was much evidence of service users being supported to make decisions about their lives. Minutes of house meetings recorded discussions about where to go on holiday. The inspector also viewed evidence of service Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 12 users choosing meals. The two new service users have had advocacy involvement for their transition from their previous home. The inspector viewed a number of risk assessments on the files of service users and was satisfied that they are supported to take risks to increase their independence. A service user recently decided she would like to walk to the post box unescorted. The deputy manager shadowed her so that she could do this. The home has a missing persons policy. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16 and 17. Service users are supported to take part in appropriate activities. Involvement in the local community is encouraged. as are appropriate leisure activities. Contact with family and friends is well supported. The home should attempt to trace a partner, with whom contact has been lost. The ethos of the home supports the rights of service users to function as independent adults as far as possible. Service users are offered a healthy diet with food having pleasant social connotations. Individual dietary needs are supported. EVIDENCE: All the service users have attended day centres during their adult lives. One individual attends a day centre three times a week, where he does woodwork which he enjoys. He also attends college once a week. Two others choose not to attend structured activities at the moment, one has done many college courses in the past. One likes knitting and one likes to do crossword puzzles with help. At home the service users like 1970’s music and ‘sit coms’ on television, also playing the keyboard which is in the sitting room. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 14 Service users take part in a number of activities. All the service users can use public transport with support. They like social activities like visiting café’s and pubs, shopping, taking short walks, feeding the ducks in the park. They have said that they don’t like museums and none of them is keen on church services, library or swimming at the moment. The manager stated that additional staff are rostered when necessary so that service users can go out and about as individuals. The organisation now has another home with some service users who are already known to the Sunflower house service users so they are expecting to socialise together quite often. They have had one group outing to Southend, ten service users and and four staff. The manager stated that the service users like the cinema and this was confirmed to the inspector in conversation with a service user. The inspector saw documentary and photographic evidence of last year’s holiday taken by service users. This pre-dates the current service users but the inspector understands that the seven day holiday is taken every year and and is funded through the contracted fees. Service users who have the funds can have additional holiday breaks although they may be asked to pay for the additional care hours needed. The manager explained the situation of each individual service user in relation to relationships with family and friends. The manager was able to view documentary evidence and was satisfied that these relationships are appropriately supported. A visitor called at the house during the inspection and was made welcome by staff. One service user has very sporadic contact with her family and the home are being pro-active in trying to re-establish contact. There is an issue for one service user who has lost contact with her next of kin over a number of years. The manager is encouraged to do all she can to trace this person. This is a recommendation. Service users have keys to their own rooms. The home has devised a policy regarding the circumstances in which staff can override the door locks and the inspector viewed this. The inspector was satisfied that the rights of service users are respected and observed them moving freely around the house. One individual chose chose to sit in the kitchen, another in the sitting room. The inspector viewed the menu plans which detailed which service user had chosen a particular meal. She also inspected the refrigerator and freezer Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 15 which contained a variety of foods. Fresh fruit was in evidence and the manager advised that all the service users like fruit and eat plenty of it. Two service users have to limit their intake of fat due to high cholesterol levels and they are encouraged to do this. One service user is rather indiscriminate in his eating and needs some supervision to eat appropriately. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 and 21. The manager is well aware of the physical and emotional needs of each service user and works to meet them. The home supports service users in a sensitive manner. However service user plans do not support or evidence this approach. The arrangements for the administration of medication in the home are good. The staff have engaged with the topic of illness, ageing and death and interacted appropriately with service users to obtain their views. EVIDENCE: The inspector was satisfied that service users receive support in a flexible way which meets their needs. However this seems to depend on staff knowledge which is not recorded on file. There was evidence of needs being assessed but the service users plans did not identify goals or translate these into care tasks. They did not detail how support should be provided. The manager is aware of this and showed the inspector some new forms which she has been working on. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 17 The inspector suggested to the manager that the plans, which are reviewed annually, are supplemented by more detailed care plans from which the staff can work supporting service users to achieve goals set. This is a recommendation. The requirement made at the previous inspection regarding the consideration of whether a service user should return to the home has been met. The service user has not returned. The manager gave the inspector verbally a health profile for each service user and a variety of physical and emotional needs were identified. The manager advised how each need is being addressed with referrals to various professionals. The manager has identified a need in one of the new service users for screening for diabetes. She is also discussing with his GP a possible referral to a psychiatrist specialising in learning disability, for advice on how to manage the service user’s hyperactivity. The inspector viewed the arrangements for the administration of medication, including the medication records and the medication policy. All was found to be in order on the day of the inspection. The inspector advised the manager that should there be a need to return unused medication to the pharmacist a signature should be obtained on receipt. The manager advised that staff have had initial discussions with two of the service users on their wishes and views regarding death and dying. The inspector saw documentary evidence on two files to support this. One service user has advised her favourite hymns and these have been recorded for use at her funeral. One service user has shown herself to be unwilling to confront issues of death and dying. She was clear that she did not want to attend the funeral of a friend. This view is being respected and has been noted on file. The service user will not be put under pressure to engage in discussion on the topic. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 only. The complaints procedure encourages service users to express their views and feel that they will be taken into account. EVIDENCE: The inspector viewed the complaints policy which has now been amended to meet the restated requirement of the previous inspection. The level of complaints is low. The manager advised that one service user has a benefit which is drawn by his sister and managed by her. This arrangement is not acceptable. The manager stated that the social worker is aware of this and will take steps to remedy the situation. The manager must ensure that the financial arrangement does not continue and if necessary must write to the social worker formally requesting appropriate action. This is a requirement. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25, 26,27, 28 and 30. The home is clean comfortable, safe and homely. Service users bedrooms suit them and support their independent and individual lifestyles. Toilets and bathrooms are adequate. The shared spaces are well decorated, nicely furnished and provide a choice of places to eat, chat, watch television and relax in. There are a mixture of smokers and non-smokers using the premises and the smoking policy is not fully adhered to. The home is clean and hygienic with appropriate policies in place. There are no offensive odours. EVIDENCE: The inspector viewed the premises, including two bedrooms, the staff sleep in room and the garden. The home is homely, comfortable, safe and free from unpleasant odours throughout. The kitchen ceiling has now been replastered and the wall repainted as required by the previous inspection. The service users bedrooms all looked comfortable and reflected the tastes of their owners with photographs, ornaments etc. A service user showed the Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 20 inspector her bedroom. She assured the inspector she was comfortable, slept well and liked her room. The firegrate, in one bedroom, subject of a previous requirement, has now been blocked up so that there is no possibility of draught coming down the chimney. The manger remarked that there are now no particles of grit coming down either. The bedrooms all promoted independence being lockable and with television. There are an adequate number of toilets and bathrooms with a bath upstairs and a shower downstairs with handrail fitted. The facilities were in good decorative order. Shared spaces were pleasant. There are artificial sunflowers and pictures of sunflowers to reflect the name of the home and this gives a nice sense of identity. The office is downstairs and large enough for service users to come in and chat, which they do. The kitchen is a good size with a table, chairs and television. There is a small courtyard with table and chairs and a small garden too. The doorbell is now working and the bannisters and spindles were all sound (meeting the previous requirement). The registered manager, manager, deputy manager and one of the service users smoke. The service user is also fixated on cigarettes and smoking. There is a smoking policy but inspector observed that it is not adhered to. The policy states that there is no smoking indoors except when it is raining when the laundry room, which has two doors to the outside, can be used with the door kept open. The policy also states that staff will not smoke in the presence of service users. The inspector observed the registered proprieter smoking in the kitchen. She observed the manager and deputy manager smoking in the courtyard which is visible from the kitchen, laundry room and office. The inspector smelt smoke in the downstairs toilet also. The inspector felt that the two service users who do not smoke were somewhat outnumbered in the house and that their rights were not being upheld or respected as the staff are flouting their own smoking policy. The inspector also felt that poor adherence to policy set a negative example to service users, and could undermine work around behaviour. Regarding the service user who is fixated on cigarettes she felt that giving him cigarettes (as staff were quite open in admitting that they do) and smoking in front of him reinforces his fixated behaviour. The manager must ensure that the smoking policy is fully implemented and adhered to. This is a requirement. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 21 The home is clean and hygienic. There is an infection control policy which addresses, food hygiene, cross contamination, infectious diseases notification, etc. All the wet areas in the home have impermeable flooring which curves up the walls to eliminate wall/floor joins. There is a policy to cover the laundering of any soiled articles. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34, 35 and 36. Staff are clear about their roles and responsibilities and are competent and qualified to support service users effectively. The staff recruitment policy is safe and robust and staff are well trained. Staff supervision and support is good but can be improved. EVIDENCE: The inspector only had the opportunity to meet with one staff who is the newly appointed deputy manager. This staff member is not experienced in residential care although she has considerable experience in domiciliary care. She will shortly take over as manager when the manager moves full time to a home which the organisation has just opened. The working relationship between the manager and the deputy manager appeared good and the inspector felt that they would make a strong team and the two homes will benefit from positive overlap. Lone working is a feature of working at the home. The usual staff ratio is one staff member to three service users, with managerial support. The night staff sleeps in and works alone. The home recognizes that there are special considerations attached to lone working and has developed a policy for this which the inspector viewed. The inspector had a discussion with the manager Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 23 regarding the fact that a lone working male staff supports female service users in the home and the implications in terms of possible allegations. The manager is aware of this consideration. The manager and staff form a culturally diverse group and have a high level of qualification overall and considerable relevant experience. The home has never so far never had to use bank staff. The inspector was satisfied that staff provide support effectively. The inspector viewed two staff files, one for a staff recently recruited and one for a staff member who has been in post for a long time. The home has improved its recruitment procedure and this is now robust with application form, references and Criminal Records Bureau (CRB) check, job description, person specification, terms and conditions of employment, code of conduct and disciplinary code, data protection contract and induction checklist. The recruitment recording could be further improved by interview notes and a recording of the decision whether or not to appoint together with the associated rationale. Also although not all documents can be added retrospectively, for staff members who have been in post for a considerable length of time, those that can be should be. For example the code of conduct could be signed by both parties, dated and added to the file. Files did now show any evidence of recording sickness and annual leave and this needs to be remedied. There are also no training profile although information regarding training exists in various places and the manager is aware of who has had what training. The manager stated that supervision should be every six weeks and regular supervision was evidenced, although there was a long gap from July 2004 until later in the year on one file. There have been no appraisals. Staff meetings take place every two months and the inspector viewed the minutes. In order to improve the management of staff the manager must do the following: Implement annual appraisal Create training profiles for staff ) Record staff absences and leave) Supervision notes ) Add code of conduct and any ) other relevant documents ) This is a requirement. all to be placed on individual personnel files Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Quality assurance is addressed by the home but service users need to hear clearly that their views underpin this. There are procedures in place to ensure that the home is safe, but the manager needs to address the issue of passive smoking. EVIDENCE: The inspector discussed quality assurance and the in-put of service users into this. She saw that some surveys had been completed by service users, also documentary evidence that person in control visits are being made regularly as required by legislation. The manager stated that she and the deputy manager are planning to ‘spot check’ this home and the new home on a regular basis, as a form of self-monitoring. They feel that they can each be objective about the home run by the other. The inspector saw the quality assurance audit form they plan to use. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 25 The quality assurance system for the home is rather underdeveloped and does not measure the home’s success in meeting its objectives. Service users may not realise that their views are important. The manager must expand and implement the system, actively seek feedback from service users and the views of relatives, visitors and stakeholders. This is a requirement. An annual development plan has been produced for the home and was viewed by the inspector. It is somewhat underdeveloped and does not reflect systematic planning-action-review with aims and outcomes for service users. The manager must ensure that the development plan is compatible with the standard. This is a requirement. The manager explained that the home has purchased the services of MJL a company who specialise in safe working practices providing policies and training. The inspector had a discussion with the manager about the interface of the home which is a workplace but needs to be domestic and homely. The inspector saw the manuals which MJL has provided and which cover risk assessment, COSHH etc. The inspector was advised that COSHH items are kept in a locked cupboard in the kitchen. There is a history of difficulty in obtaining product information and the home were forced to write their own, which the inspector saw. This is one of the things the manager expects to improve with MJL. The inspector viewed the fire risk assessment and the record of fire drills. She checked the records for fire equipment, gas safety, PAT testing etc and was satisfied that the safety is taken very seriously in the home. The inspector is satisfied that the safety and welfare of service users is promoted and protected but would refer to standard 28 where a requirement has been made to protect service users from passive smoking. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brandley Residential Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 27 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The manager must ensure that the statement of purpose includes the information of her qualifications (previous timescale of 10/9/04 not met). The manager must ensure that the smoking policy is fully implemented and adhered to. The manager must expand and implement the quality assurance system as detailed in the main body of the report. The manager must ensure that the annual development plan for the home is compatible with the standard as detailed in the main body of the report. The manager must ensure that the all service users have appropriate appointee arrangements. In order to improve the management of staff the manager should undertake the actions details main body of the report. Timescale for action 01 August 2005 2. 3. 28 39 12 and 23 24 01 August 2005 01 September 2005 01 September 2005 01 September 2005 01 September 2005 4. 39 24 5. 23 12 6. 36 18 Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 28 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 15 18 Good Practice Recommendations The manager is encouraged to do all she can to trace the next of kin of a service user who has lost touch with this person. The manager should supplement the overall care plan with more detailed care plans as detailed in the body of the report. Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 29 Commission for Social Care Inspection 4th Floor, Gredley House 1-11 Broadway, Stratford London E15 4BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brandley Residential Home G57 G06 S22856 Brandley Rest Home V220848 010605 Stage 4.doc Version 1.20 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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