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Inspection on 15/06/06 for Bransfield Manor Rest Home

Also see our care home review for Bransfield Manor Rest Home for more information

This inspection was carried out on 15th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Resident`s views are continually sought to improve the service the home provides. This is undertaken by listening and talking to residents. The inspector spoke to the majority of residents, all were complimentary towards the staff, regarding the care provided and the staff team. Residents living in the home appeared to be happy; they were well dressed and enjoyed their lunch on the day of the site visit. Lunch is served in the dining area, the tables were nicely laid the food was plentiful and appeared appetising and nourishing. The inspector spoke with all the staff on duty on the day of inspection, staff commented they feel supported by the manager and work as a stable team. It was pleasing to note that the home has provided a mobile telephone for a resident who likes to go out on her own. The telephone number of Bransfield Manor is printed on the back of the telephone, and the number of the mobile telephone is also printed on the back, to enable the resident to use the telephone when necessary.

What has improved since the last inspection?

It was difficult for the inspector to evaluate any improvements to the home due to the fact that three requirements from the previous inspection had not been met, these requirements will be carried forward to this inspection report. This was the first visit to Bransfield Manor by the inspector, therefore it was difficult to make a judgement.

What the care home could do better:

A quality audit needs to be undertaken in the home on a regular monthly basis this needs to be carried out by the responsible individual or a representative. It would be highly recommended that management of the home check for any areas needing attention, are regularly maintained and a record be held on file.It was disappointing that there were a number of ongoing areas that require attention. The management of the home needs to review their performance and should ensure the National Minimum Standards for Older People and the Care Homes Regulations 2001 are adhered to at all times.

CARE HOMES FOR OLDER PEOPLE Bransfield Manor Rest Home Bransfield Manor Church Lane Godstone Surrey RH9 8BW Lead Inspector Vera Bulbeck Unannounced Inspection 15th June 2006 10:30 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 Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bransfield Manor Rest Home Address Bransfield Manor Church Lane Godstone Surrey RH9 8BW 01883 742927 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) Family Care Private Company Limited Wanni Aylward Care Home 17 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (17), Sensory Impairment over 65 years of age (1) Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The combined total of residents falling into the category DE(E) and/or MD(E) must not exceed six (6) 7th November 2005 Date of last inspection Brief Description of the Service: Bransfield Manor is a care home registered for provision of personal care for older people from the age of 65 years. The home has a combined total of six places for the care of older people with either a diagnosed dementia or mental disorder, excluding learning disability. Additionally within the total numbers one placement may include an older person with a sensory impairment. The building is a large, detached Victorian property, situated in a semi -rural location, off a quiet country lane. The home is a short distance by car to Godstone village and accessible to larger shopping facilities in nearby towns. Bedroom accommodation is on three floors accessible by chairlift. Bedrooms on the second floor are only suitable for fully ambulant service users however. Communal lounge and dining facilities are available on the ground floor and assisted bathing facilities. Though the home has extensive gardens, the undulating, large rear garden is not suitable for use by service users. In fine weather service users enjoy sitting in a pleasant designated courtyard area to the side of the home or by the front door overlooking the car park. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection for the year April 2006 to March 2007. The site visit was over a period of eight hours thirty minutes. For details of how each standard was met please refer to the main body of the report. The site visit was unannounced, which meant that visitors, staff and residents were not aware of the visit prior to it commencing. The inspector had the opportunity to speak with a number of residents who live at the home. The majority were very complimentary about the home and staff. A full tour of the premises was undertaken. Four care plans were observed. There were three members of staff on duty, the registered manager, proprietor and there were seventeen residents in the home at the time of arrival. All members of staff were spoken with during the visit. It was disappointing to note that three requirements from the previous inspection had not been met and have been carried forward to this inspection report. A letter of serious concern was sent regarding cleaning materials, which must be stored appropriately at all times, following the site visit on 15/06/06. A number of comment cards were left for residents and relatives to complete and requested they be returned to Commission for Social Care Inspection (CSCI) Eashing Office. Mrs V Bulbeck, Lead Inspector for the service carried out the site visit. Mrs W Aylward the Registered Manager and Mr N Samarasekara proprietor of the home was present. The home is registered for seventeen places. There are currently seventeen residents living in the home. The home has a waiting list. The range of fees for the home are from: £378.00 - £475.00. The staff was observed to be courteous and the atmosphere within the home was relaxed and friendly. The inspector would like to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. An improvement plan must be submitted to the Commission for Social Care Inspection (CSCI) with dates and timescales regarding the requirements made at the site visit on 15/06/06. To be submitted by 28/07/06. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A quality audit needs to be undertaken in the home on a regular monthly basis this needs to be carried out by the responsible individual or a representative. It would be highly recommended that management of the home check for any areas needing attention, are regularly maintained and a record be held on file. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 7 It was disappointing that there were a number of ongoing areas that require attention. The management of the home needs to review their performance and should ensure the National Minimum Standards for Older People and the Care Homes Regulations 2001 are adhered to at all times. 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. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the resident’s identified needs. The home does not offer intermediate care. EVIDENCE: At the time of the visit it was noted that a resident had recently visited the home for a pre assessment this was undertaken with the residents social worker and management of the home to ensure the home is able to meet the residents needs, prior to admission to the home. The management of the home needs to update the statement of purpose and the service users guide and a copy should be provided to all residents, and relatives need to be provided with a copy particuarly, if a resident is unable to be involved with the care provided in the home. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 10 It was identified at the time of the visit that the registered manager and all staff need to attend equality and diversity training. The home does not offer intermediate care. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,and 10. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place, management of the home needs to ensure the safe administration of homely remedies and appropriate risk assessments need to be in place. Management of the home needs to ensure all accidents and incidents notify able under Regulation 37 need to be sent to the Commission for Social Care Inspection (CSCI) within 24 hours. EVIDENCE: Four residents care plans were sampled and there was evidence that resident’s health, personal and social care needs had been identified and assessed. Care notes are in the process of being updated and more detail included in the few already changed. Resident’s needs should relate to equality and diversity. It was noted correction fluid was used on a residents’ care plan correction fluid must not be used on legal documents. There is a need to ensure all care plans are up to date and each hold relevant details as stated in the Care Homes for Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 12 Older People National Minimum Standards and the Care Homes Regulations 2001, Schedule 3. It was noted in a care plan a resident had gone missing from the home, the police were involved and the family were informed. This has happened on three occasions and the CSCI were not notified of the incidents. A number of risk assessments need to be updated for all residents living in the home. Including a recommendation from the doctor regarding a resident who stated, that the resident should sit as she has oedema in her eyes. This particular resident spends a lot of time in bed. The resident refuses to sit in a chair and this should be clearly documented in her care plan. It was noted in one residents bedroom there were no clothes in either his wardrobe or his chest of drawers, the bedroom was totally bare, the inspector was informed the reason for this is because the resident tends to pack his possessions into a case. The inspector would advise for the management to look at other methods of care for this resident and full details need to be documented in the residents care plan. Medication records were found to be well documented. However, it was noted that one resident’s buys medication from the local chemist and on the day of the site visit it was noted that medication had been left on the resident’s bedside table. The resident, who had gone out, had locked the bedroom door. The inspector advised the manager to check with the doctor if the homely remedy was appropriate to be taken with the medication already prescribed by the G.P. Storage facilities were appropriate. Medication is administered from blister packs and two members of staff are involved with the process. The residents spoken to confirmed that staff are respectful and knock on the door before entering. Observation by the inspector was residents and staff have a good rapport, residents are able to discuss with the staff any worries they may have and staff reassure residents, by supporting, explaining, and helping to clarify any problems and to ensure residents have a clear understanding. The hairdresser was present in the home on the day of the site visit; she stated she visits on a two weekly basis. It was noted that a resident’s bedroom is used for the purpose of hairdressing. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 13 The inspector was informed the resident has kindly agreed for her bedroom to be used for this purpose. The inspector advised the management to consider using another area for the purpose of hairdressing, management must ensure this information is documented in the residents care plan and signed by the resident, care manager or her family. The hairdresser stated that residents discuss with her about how happy they are living in the home, she has always received good feedback from the residents. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to maintain contact with family and friends. Meals are well balanced and varied with individual choices and preferences as well as special dietary needs catered for. EVIDENCE: The Majority of residents have contact with family and friends except two residents. The inspector advised the home to contact Age Concern regarding obtaining an Advocate for the two residents without family contact. The meals served in the home were nutritional in content and well balanced. The staff and residents are involved with the menu planning and the home has a cook who undertakes the cooking duties on a daily basis. One resident confirmed the food is very good. Any changes to the menu must be recorded. There is a planned activity programme one afternoon a week and from time to time extra musical performers are invited to the home. An in house activity programme is organised by the staff and during the afternoon, time permitting staff spend time with the residents. The residents seem to spend a lot of their time chatting in the lounge or entrance hall, all appeared to be happy and Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 15 those spoken to confirmed they were happy to be living in the home, and one resident stated the staff are very nice and helpful. Another resident who was sitting in the lounge not particularly watching what was on the television, when the inspector asked him if he liked football he commented he did, at the time there was a match playing in the world cup. The member of staff was requested to switch the football on for the residents. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure, which includes timescales for the process. However it does need to be updated. All required policies and procedures are in place to ensure that residents are safeguarded from harm or abuse. EVIDENCE: There have been no recorded complaints in the home since 2003. The home has developed its complaints procedure and currently has documented the National Care Standards Commission (NCSC), which has been changed some time ago to the Commission for Social Care Inspection (CSCI). Details of the CSCI needs to incorporated in the complaints procedure. The inspector advised the management of the home to ensure all residents and relatives where necessary are provided with a copy of the complaints procedure. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and all staff has received the protection of vulnerable adults training. Staff on duty confirmed they had undertaken this training and were aware of the procedures. The home has a copy of Surrey Multi Agency procedures. Residents are encouraged to vote and some have been registered for a postal vote. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 17 Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is situated in a very rural part of the village, Church Lane does not have a pavement to walk on. Therefore this poses a problem for a resident who goes out on a regular basis. The gardens in the home are vast and require considerable attention; some of the work needed to be undertaken has been addressed. An ongoing maintenance and redecoration programme provides the residents with clean, pleasant and homely surroundings in which to live. EVIDENCE: The home was found to be clean and tidy, there is a domestic who works on a part time basis and staff undertakes some of the cleaning duties on a daily basis, particularly at weekends when cleaning is covered by the care staff. Some of the residents like to be involved with the cleaning in their bedrooms. There are several areas around the home that have a nice homely touch and residents enjoy, some areas could be improved, particularly the area outside Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 19 the kitchen. One resident likes to walk in this part of the home, as it is the only access for the residents to walk outside the home without staff. The resident suggested the area could be made into a nice courtyard sitting area for residents to sit and enjoy. The resident also commented the “drain needs to be covered”. It was noted that a number of areas around the home are in need of attention. In some bedrooms the carpets were found to be badly stained, in need of deep cleaning or replacing. It was also noted at the entrance to bedroom 18 the carpet had come out of the carpet strip which holds the carpet in place, therefore could be hazardous to the residents or staff, also the handle on the door needed attention. Some residents were without a bedside light and two windowpanes were broken, the glass needed to be replaced. The wall on the top landing needed attention where at one time there had been a leak from the roof window. The staff sleeping in room needs a lock fitted to the door to ensure when leaving the window open residents are unable to access the room and are therefore safe. Several residents’ bedrooms were without a two-way lock; some of the locks had a locking device and in the event of an emergency staff would be unable to access the bedroom. Any bedrooms where the residents require the bedroom door to be opened all the time should have an automatic door release fitted; this needs to be fitted to the fire alarm system. Bedroom doors must not be wedged open as seen on the day of the site visit. On a small balcony leading from the bathroom on the top floor there was an old chair, which needs to be removed. In one residents bedroom the pillowcase was very dirty and stained, all beds should have a mattress protector to enable the cover to be removed for washing purposes and also it is more hygienic. The fire exit door on the top landing needs replacing as it is very weathered and the wood is rotten at the bottom. The outside of the home needs painting and several windows need replacing. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets resident’s needs. The home has a comprehensive staff recruitment and training programme which incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. EVIDENCE: There is adequate staff on duty during each shift, these include three care staff, domestic staff and the chef. Management needs to review the staffing levels to ensure the registered manager has appropriate time to undertake the management tasks required. A maintenance person who covers another home as well as Bransfield Manor visits the home on a regular basis and carries out all the maintenance jobs required. Full recruitment procedures are mainly being followed. All staff has been checked against the Criminal Records Bureau (CRB) before working in the home. Staff records were observed and found to be well documented, including contracts and terms and conditions. However, it was noted that the hairdresser needs to be CRB checked. Training has been ongoing and the majority of staff has attended a number of training courses. A training plan has been produced and was up to date. All new staff has a comprehensive induction-training programme. All staff has received (POVA) protection of vulnerable adults training. Three members of Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 21 staff are on the waiting list to commence NVQ Level 2. Two members of staff are waiting to commence NVQ Level 3. Training has been identified as a priority. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Resident’s, benefit from an open, positive and inclusive management style. The home has a monitoring system in place that is based on seeking the views of the residents. All policies, procedures and practices are in place, but some need updating to ensure, so far as is reasonably practicable, the welfare, health and safety of residents and staff. EVIDENCE: The management of the home need to review their management practices to ensure the home is meeting the required standards. The management of the home needs to comply with the National Minimum Standards for Older People, and the Care Homes Regulations 2001. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 23 The registered manager has one unit to complete of the Registered Managers Award and aims to be completed by the end of July 2006. A questionnaire (Customer Care Satisfaction) is sent to all relatives on a yearly basis and nine questionnaires were returned on the last survey the majority stated they were satisfied with the care received and two commented there could be more activities and involvement with the local community. The registered manager informed the inspector resident’s finances are managed by the relatives, the home does not manage residents finances, the majority of residents have family who are involved and those without family have a solicitor who has power of attorney. However, the proprietor informed the inspector that any payments for hairdressing or chiropody is paid by the home and a monthly invoice is sent to relevant parties for payment. At the time of the previous inspection it was agreed to contact the EHO and the Environmental Health Officer undertook a visit and a letter was received from the EHO on 22/03/06 and several areas required attention. Areas of work outstanding has been completed. In the bathroom on the top floor cleaning materials were found. The items were removed immediately by the registered manager. The laundry has a bolt on the door however, the door needs to be kept locked with a key particularly when the area contains cleaning materials and several tins of paint were found under the sink. The home needs to exchange a washing machine for a machine with a sluicing facility. This was discussed at the time of the site visit and the proprietor was made aware and agreed to change a washing machine to a more appropriate model for the home. There are several drains around the home, which need a cover. It was also noted there was some rubbish in the garden which, needs to be cleared from behind the kitchen. The maintenance book needs to be kept up to date When testing the call bells staff did not respond as one member of staff stated that she thought we were undertaking a test. Staff must be made aware and be clear regarding the testing of the system and should respond at all times unless advised not to. Further training required in this area. A number of records were checked including the fire records and the inspector advised the home to implement an emergency contingency plan and to ensure the fire risk assessment is kept up to date. The water needs to be tested, and recorded on a regular basis. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 2 Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 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 OP1 Regulation 6 Requirement For the statement of Purpose and Service Users Guide to be updated with details of the manager. The Service Users Guide should also refer to provision made on request of a safety lock on bedrooms doors and key, subject to risk assessment and of a lockable item of furniture in bedrooms. (Timescale for action 07/01/06) For care plans and risk assessments to be further developed and reviewed at least monthly. Staff should ensure care notes are recorded in sufficient detail. (Timescale for action 07/12/05) For compliance with the statutory requirement for providers not in day - to - day charge of homes to visit the home unannounced on a monthly basis and interview staff, service users and their representatives in order to form an opinion of the standard of care. To also inspect the DS0000042991.V294751.R01.S.doc Timescale for action 28/07/06 2. OP7 12, 13, 14 &15. 28/07/06 3. OP31 26. 28/07/06 Bransfield Manor Rest Home Version 5.1 Page 26 4 5 6 OP37 OP19 OP19 17 23 23 premises and records of events and of any complaints and prepare a written report on the conduct of the home which must be available for inspection. (Timescale for action 07/12/05). Correction fluid must not be used 07/07/06 on legal documents. Carpets in some bedrooms need 07/07/06 to be deep cleaned or replaced. The garden needs to be cleared 07/07/06 of overgrown areas particularly where the fire escape is situated. Bedding needs to be clean at all times. To provide a mattress cover for all beds. Full recruitment procedures must be followed including a CRB for the hairdresser. To maintain and record work outstanding in the maintenance book. The fire exit door on the top floor needs repairing or replacing. Rubbish to be removed from the garden including a chair from the bathroom balcony. Broken windowpanes need replacing. Bedside lights to be provided for all residents. Locks on bedroom doors need to be reviewed and some locks to be fitted. All significant accidents and incidents must be reported and sent to the CSCI within 24 hours. To produce an emergency contingency plan and to ensure the fire risk assessment is kept up to date. To check and record the water temperature on a regular basis. Bedroom doors must not be wedged open, appropriate automatic door closures must be DS0000042991.V294751.R01.S.doc 7 8 9 10 11 12 13 14 15 OP38 OP29 OP19 OP19 OP19 OP19 OP24 OP24 OP38 23 18 &19 16 13 23 23 16 16 17 15/06/06 11/08/06 07/07/06 07/07/06 28/07/06 07/07/06 28/07/06 28/07/06 07/07/06 16 OP38 13 28/07/06 17 18 OP38 OP38 13 23 07/07/06 28/07/06 Bransfield Manor Rest Home Version 5.1 Page 27 fitted. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP9 OP16 OP19 OP19 OP15 OP19 Good Practice Recommendations To discuss with G.P service user’s purchasing and taking homely remedies. Complaints policy needs to be updated and all residents or relatives should receive a copy. For the rear garden to be tidied and landscaped and made safe and accessible for service users’ use. Outside drains to be fitted with a cover. Any changes to the menu must be recorded. Hairdressing arrangements to be reviewed. Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Bransfield Manor Rest Home DS0000042991.V294751.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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