Inspection on 21/03/07 for Bransfield Manor Rest Home

This inspection was carried out on 21st March 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

Bransfield Manor Rest Home 10/12/07

Bransfield Manor Rest Home 15/06/06

Bransfield Manor Rest Home 07/11/05

Bransfield Manor Rest Home 05/05/05

Bransfield Manor Rest Home 13/09/04

Bransfield Manor Rest Home 13/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bransfield Manor Rest Home Bransfield Manor Church Lane Godstone Surrey RH9 8BW Lead Inspector Pauline Long Unannounced Inspection 21st March 2007 09:30 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.V330015.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. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 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.V330015.R01.S.doc Version 5.2 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) 15th June 2006 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. The fees at the home range from £375 pounds to £450 pounds per week. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second site visit of a key inspection and was unannounced. The inspection was carried out by Mrs P Long regulation inspector and lasted for 6 hours, commencing at 09.30 and ending at 14.30. Discussions were held with residents, the manager and staff. Service documentation was sampled, and included residents files, care plans, staff records, and service files. Care staff were observed going about their work. A tour of the home took place. Some residents were keen and happy to talk about life in the home. Verbal feedback from other resident’s at home on the day was limited, in view of their communication difficulties. However their body language, facial expressions and observations of their interaction with each other and care staff, evidenced a state of general wellbeing. The CSCI would like to thank the residents, the manager and staff for their hospitality, assistance and co-operation during the site visit. What the service does well: What has improved since the last inspection? The majority of the requirements made at the last inspection had been met. Improvements have been made in the care needs assessment, care planning and risk assessment process. The recording of information on the residents care plans has improved and provides the reader with a good overview of a resident’s needs. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 6 Improvements have been made in respect of the overall environment. Five bedrooms have been re-carpeted. A new exit door has been installed between the top floor and the fire escape. The broken windowpanes have been replaced. Bedside lights have been placed in all of the resident’s bedrooms. Some of the bedroom doors have been fixed with automatic door closures. Keypads have been fixed to the kitchen and office doors in order to ensure that any risks to the residents are minimised. All of the exit doors have been alarmed in order to alert staff if a resident leaves the building. Some areas of the home have been redecorated providing a more pleasant environment for the residents. What they could do better: Whilst it is noted that the care needs assessments, care plan documentation and risk assessment has improved. Further work is required in these areas. Resident’s and/or their representatives must be given the opportunity to read, agree with and sign their care plans. There must be a corresponding care plan in place for all of the care needs identified. Risk assessments must be undertaken on those resident’s who go out of the home on unaccompanied walks. A requirement was made at the previous inspection in respect of the overall environment. It was noted that some work has been undertaken in this respect. However the providers must ensure that the regular checks are carried out on any and all areas requiring attention. Attention must be paid to some of the bedroom carpets on the first floor, these must be kept clean or replaced. Some areas of the kitchen hygiene require attention to ensure the continued health, safety and welfare of the residents. It was also noted that a large area of the garden had been improved, further work is required to ensure that all areas of the gardens are safe for the residents to use. The patio area to the back of the house must be cleared of trip hazards. The home has implemented a formal staff supervision process, however to ensure the continued health, safety and wellbeing of the residents improvements are required to ensure that all staff receive at least 6 one to one meetings with a manager. Requirements have been made in respect of these standards. Please refer to pages 26 and 27 and of this report. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 7 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. Bransfield Manor Rest Home DS0000042991.V330015.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 Bransfield Manor Rest Home DS0000042991.V330015.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are only admitted to the home following an assessment of their needs. The home does not provide an intermediate care service. EVIDENCE: Referrals to the service, come from privately funded and social services clients. The manager stated that she would visit the prospective resident at their home or hospital to carry out a care needs assessment. The prospective resident and/or a representative would then be encouraged to spend time at the home prior to making a decision as to whether the home could meet their needs. Due to their communication difficulties, residents were unable to confirm that a member of staff had visited them prior to them being admitted to the home. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 10 Three of the residents care needs assessments were sampled and were found to provide a holistic view of the residents care needs, for example, how they like to be referred to in respect of their name, health and social care needs, spiritual needs and likes and dislikes around activities. The home does not provide an intermediate care service. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans sampled were satisfactory. Improvements are required in the care planning process to ensure that all identified needs have a corresponding care plan in place. Residents care needs were well met. Residents are not responsible for their own medication and are protected by the homes medication policies and procedures. Staff were observed to treat residents respectfully and their right to privacy was upheld. EVIDENCE: Three of the residents care plans were sampled. The care plans were satisfactory, and had been reviewed. The documentation contained Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 12 information regarding all activities of daily living, changes in healthcare needs and various visits from health care professionals. A resident commented, that, “the care they received at the home was good”. It was noted that one care plan required further work, as needs identified in the care needs assessments did not have a corresponding care plan in place in order to ensure these needs were being met. On the day of the visit, medication administration was not observed. The storage of medication was found to be good. None of the residents in the home required controlled medication. Medication record sheets were sampled, and were found to be well kept, with no gaps in signatures noted. Instructions in respect of a resident’s homily medications are now recorded on the medication record sheets. Copies of the general practitioners instructions in this respect were evidenced on the respective resident’s files. Discussions were had with the care staff about the homes medication policies and procedures. It was evident through discussions, that the staff had a good understanding of these policies and procedures. The staff commented, that only those staff, who have undergone training in administration of medication and who are assessed as competent are permitted to administer medications. Training records evidenced various medication training days. The manager commented that the staff would be undertaking a more in-depth training course in the safe handling of medications in the next few months. Through out the inspection process, staff were observed carrying out various aspects of personal care for the residents, this support was offered in a respectful and quiet manner. Staff were observed knocking on doors and waiting to be invited in, before entering rooms. Bathroom doors were kept closed whilst staff were attending to residents personal care needs. One resident commented that, “all of the staff were kind and treated her with respect”. A requirement was made in respect of these standards. Please refer to pages 26 and 27 of this report. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are encouraged to make choices and enabled to maintain fulfilling lifestyles in the home. The home promotes contact with family and friends. Meal times in the home were observed as being a positive and pleasant experience for the residents and the food looked appetizing. EVIDENCE: The home is committed to ensuring that the residents maintain their relationships with their family and friends. One resident commented that she received visits from her family from time to time. One relative visited the home during the site visit, to take his relative out to lunch. There were various flyers posted on notice boards, relating to future outings/activities. Care needs assessments and care plans related to residents likes and dislikes around activities. It was noted on the day of the visit, that no activities were being undertaken. The majority of the residents were sitting quietly in their in their armchairs. Four residents were happily chatting in the front hall. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 14 Discussions were had with the manager and staff in respect of the activities offered at the home. One member of staff commented that, the staff did not always have the time to involve the resident’s in activities. Another member of staff stated that, the residents are encouraged to take part in an extend exercise class , bingo and arts and crafts. These activities are provided by someone from the local community. There were photographs of the residents undertaking these various activities, and evidence of the various arts and crafts sitting around the home. One resident commented “the staff were always trying to get her involved in doing things, but she just liked to sit in her bedroom and watch the birds”. The home has arranged for weekly visits from the local church. One resident commented that the Vicar comes to the home every week to bring her communion. Throughout the visit, residents were observed moving freely around the home, making choices as to where they would sit and what they would like to eat and drink. It was noted that one resident left the home unaccompanied, the staff were aware of their movements. Subsequent discussions had with the staff in respect evidenced that this resident had a degree of dementia. No risk assessments had been completed in order to ensure that any risks related to this activity had been minimised. The meals are freshly cooked in the home and it was positive to note, the choice of food on offer was good. The food was served up directly from the kitchen to the dining room tables. The food appeared appetizing and the residents commented that it was lovely and they appeared to be enjoying it. There was good evidence to suggest residents were offered choices in respect of their meals, as it was noted that the several residents were eating different meals. One member of staff was observed encouraging the residents to eat their food and was supporting those residents who required help. This support was offered in a dignified and sensitive way. Throughout the site visit staff were mindful of the need to encourage the residents to have drinks. Fresh fruit was available for the residents if they wished to eat it. One relative commented that, they “ would like to see a more varied menu”. The cook demonstrated a good understanding of each resident’s likes and dislikes, and specialist diets for example diabetic, vegetarian, soft diet. During the lunch time activity it was noted that one resident’s meal was presented in a bowl and had been blended together. The staff commented that the resident in question needed a soft diet due to their inability to feed them selves. Discussions were had with the manager in respect of how this food was presented and the need for all food to look appetizing and appealing. It was noted that whilst on the whole the kitchen was well maintained. Improvements are required in the cleaning regime. The areas of the floor around the dishwasher and cooker were dirty, with evidence of a build up of food debris. One of the fridges was observed as being somewhat old and it Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 15 was noted that, the door handle was broken, this had a sharp edge which had the potential to pose a risk to the staff. Requirements and a recommendation have been made in respect of these standards. Please refer to pages 26 and 27 of this report. Bransfield Manor Rest Home DS0000042991.V330015.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): 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 residents are protected by the homes policies and procedures around concerns, complaints and protection. EVIDENCE: CSCI have not received any complaints about this service since the last inspection. The manager stated that the home had not received any complaints. The complaints log was sampled and evidenced that the last documented complaint was in 2004. One resident commented that if she had to make a complaint, she would speak with the manager. No referrals have been made under the local authority multi agency Safeguarding Adults procedures. Discussions were had with all of the staff on duty and scenarios put to them in respect of the home’s safeguarding adults procedures. Staff interviewed demonstrated a good understanding of the policies and procedures. The staff stated that they had all undertaken training in this respect, and this was evidenced in the homes training records. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst overall the standard of the environment within this home is satisfactory and meets the needs of the residents, improvements are required in respect of the hygiene standards in some of the resident’s bedrooms and in the maintenance of the outdoor areas. EVIDENCE: Bransfield Manor is an older property and therefore presents many challenges for the providers in respect of the ongoing need for updating and refurbishment. Several improvements have been made since the last inspection. Five bedrooms have been re-carpeted, a new exit door has been installed between the top floor and the fire escape. The broken windowpanes have been replaced. Bedside lights have been placed in all of the resident’s bedrooms. Some of the bedroom doors have been fixed with automatic door Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 18 closures, which benefits those residents who wish to sit in their bedrooms and keep their doors open. Keypads have been fixed to the kitchen and office doors in order to ensure that any risks to the residents are minimised. All of the exit doors have been alarmed in order to alert staff if a resident leaves the building. The laundry door has had a lock fixed to it. A new bath hoist has been installed in the downstairs bathroom. It was noted that one of the stair lifts was not working. This was brought to the attention of the manager and was addressed by the maintenance man whilst the inspector was in the building. A maintenance log has been implemented and appears to be working well, with environment issues identified by the staff and addressed by the maintenance man in a timely manner. There is a continued need for the ongoing updating and refurbishment in respect of the property. The area of the garden directly outside the home has been tidied up, the grass has been cut and the area looks quite pleasant. The garden area directly below the fire escape has been cleared of overgrowth. It was noted that the patio adjacent to the fire escape requires attention. Several tufts of grass have grown in between the paving stones, and have the potential to pose a considerable trip hazard to the residents. A resident’s bedroom is no longer used for hairdressing purposes. The downstairs cloak-room is now used in this respect. It was noted that the shape of the wash-hand basin did lend its self to promoting a residents comfort whilst having their hair washed. This was brought to the attention of the Registered Provider. Many areas around the home benefit from a homely touch. On the whole the home was found to be clean and tidy, no malodours were noted. Care staff undertake all of the cleaning duties as part of their daily work. One resident commented that her room “was always well cleaned”. It was noted that the carpets in some bedrooms on the first floors were badly soiled, particularly around the wash hand basins. These carpets are in need of need of deep cleaning or replacing. As discussed earlier in this report , improvements are required in respect of the cleaning regime and in the maintenance of kitchen equipment. Requirements have been made in respect of these areas. Please refer to pages 26 and 27 of this report. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels were adequate for the resident’s dependency levels/numbers. On the whole the residents are protected by the homes recruitment practices and staff training. Improvements are required in respect of the records kept of the staff interview process. EVIDENCE: The home employs a diverse staff group. On the day of the site visit staffing levels were adequate for the dependency level of the residents, and consisted of 2 care staff, one cook. The manager was due in on a late shift. The homes recruitment practices were sampled, and on the whole were found to be good. Three staff files were sampled and all had the required documentation in place. However there was no evidence of, or any records kept in respect of the staff interview process. This need for the home to demonstrate their recruitment procedures and practices are based on equal opportunities was discussed with the manager. It would be good practice to have a record of the questions asked and the responses received. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 20 Discussions were had with staff, who, talked about their job roles and responsibilities. Work based observations evidenced, quiet and competent staff carrying out their various tasks. Staff discussed the training opportunities in the home. Training records demonstrated that statutory and various current good practice training had been undertaken since the last inspection for example: food hygiene, dementia, POVA, depression and equality and diversity. The home is proactive in promoting NVQ (National Vocation Qualifications). Eight members of care staff are undertaking NVQ qualification. Manual handling training has been booked for April 2007. The manager commented that all of the staff would be undertaking further training in respect of the safe handling of medications. Requirements have been made in respect of these standards. Please refer to pages 26 and 27 of this report. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced, qualified and competent to run the home. The residents and staff benefit from her management approach. Resident’s financial interests are safeguarded by the homes financial procedures and practices. Improvements could be made in respect of a resident’s/relative’s confidentiality around the storage of invoices and receipts. Improvements are required in the formal one to one staff supervision process and records kept in this respect. Improvements are required in respect of some health and safety aspects at the home. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager is experienced and competent to run the home. She has recently completed the Registered Managers Award. Staff commented that the resident’s, benefit from the managers “ hands on approach” to the running of the home. A service user questionnaire is sent to all relatives on a yearly basis. Several were returned with mostly positive comments for example: “The kindness and consideration shown to my relative is excellent”, and “visitors are most welcome”. Some relatives commented that “ there could be more in the way of activities” and “ would like to see a more varied menu”. Discussions were had with the manager around resident’s personal monies. She stated that resident’s families/representatives had overall responsibility for resident’s monies. However the home would pay for hairdressing, chiropody and other various items, they would then invoice the relevant parties for payment. There was evidence of various receipts and invoices in this respect. The home may wish to consider a resident’s/relative’s confidentiality and the appropriateness of keeping these receipts and invoices on the office notice board. Discussions with the care staff indicated that one to one staff supervision meetings were held. The staff and manager commented that they regularly work together and have regular discussions around residents needs. The only record kept was a programme of supervision dates, and this programme evidenced that staff had not received a formal one to one supervision meeting since august 2006. Discussions were had with the manager in respect of the need to document the discussions undertaken with staff, both informally and more formally at one to one staff supervision meetings. The staff commented that, they are also expected to attend regular team meetings. The last team meeting was held on 23/10/06. Health and safety checks carried are routinely carried out at the home. Records evidenced that water temperatures, fire drills and fire bells had been regularly checked. All equipment in the home had been properly maintained and serviced. As discussed earlier in this report, improvements are required in respect of trip hazards in the garden and risk assessments around a resident’s safety outside the home. Requirements have been made in respect of these standards. Please refer to pages 26 and 27 of this report. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 23 Bransfield Manor Rest Home DS0000042991.V330015.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 2 X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 1 X 2 Bransfield Manor Rest Home DS0000042991.V330015.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 OP7 Regulation 15(1) Requirement The registered person(s) must ensure that all of the resident’s identified care needs are met. All care needs must have a corresponding care plan in place. The registered person(s) must ensure that all residents or their representatives are encouraged and given the opportunity to agree to, and sign their care plans. If this is not possible then the reasons for the lack of signatures must be clearly documented in the individuals care plan. The registered person(s) must ensure that any activities which service users participate in are so far as reasonably practicable free from avoidable risk. Risk assessments must be undertaken on all of the resident’s who leave the building unaccompanied. The risk assessments must be documented and reviewed at regular intervals. The registered person(s) must ensure that any unnecessary DS0000042991.V330015.R01.S.doc Timescale for action 21/04/07 2. OP7 12(3), 15 21/05/07 3. OP7 12 (1)(a), 13(4)(a(b (c ) 15(2)(b (c ) 21/04/07 4. OP19 12(1)(a) 13(4)(a(b 21/04/07 Bransfield Manor Rest Home Version 5.2 Page 26 (c ) 23(2)(O) 5. OP26 23 (2)(b(d) 6. OP26 16(2)(j) 7. OP15 16(2)(g) 7. OP36 18(2)(a) risks to the health and safety of the residents are identified and so far as possible eliminated. The patio area at the rear of the building must be cleared of the overgrown grass tufts. The registered person(s) must ensure that all parts of the home are kept clean and reasonably decorated. Carpets in some of the first floor bedrooms must be deep cleaned or replaced. The registered person(s) must make suitable arrangements for maintaining satisfactory standards of hygiene in the home. All areas of the kitchen must be kept clean. The registered person(s) should provide suitable kitchen equipment. The broken fridge must be replaced. The registered person(s) must ensure that persons working at the home are appropriately supervised. All staff must receive at least 6 formal one to one meetings with a manager. Clear and accurate records must be kept of the issues discussed at these meetings. 21/05/07 21/05/07 21/05/07 21/05/07 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 OP29 OP15 Good Practice Recommendations It is recommended that the home develop the staff interview process by developing a list of questions and expected responses based on equal opportunities. It is recommended that the home review the presentation of meals in respect of a resident. The food should look DS0000042991.V330015.R01.S.doc Version 5.2 Page 27 Bransfield Manor Rest Home 6. OP21 OP22 appetizing and appealing It is recommended that the home review the appropriateness of the hair washing facilities in place for hairdressing arrangements. Bransfield Manor Rest Home DS0000042991.V330015.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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