Inspection on 14/12/06 for Branthwaite Care Home

This inspection was carried out on 14th December 2006.

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

Branthwaite Care Home 28/01/09

Branthwaite Care Home 27/09/05

Branthwaite Care Home 13/06/05

Branthwaite Care Home 17/03/05

Branthwaite Care Home 16/06/04

Branthwaite Care Home 25/02/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Branthwaite Care Home 34 Welham Road Retford Nottinghamshire DN22 6TN Lead Inspector Karmon Hawley Key Unannounced Inspection 14th December 2006 10:00 X10029.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 Branthwaite Care Home DS0000008638.V325001.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 and Care Homes for Adults 18 – 65*. 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. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Branthwaite Care Home Address 34 Welham Road Retford Nottinghamshire DN22 6TN 01777 706720 01777 706720 rocky@fbccarehomes.com www.fbccarehomes.com FBC Care Homes Limited 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) Mrs Leelah Manee Sooriah Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (21) Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users shall be within categories MD/E (21), DE/E (21) or MD (2) within a total registration of 21 beds Non ambulant service users shall be accommodated on the ground floor Date of last inspection 3rd February 2006 Brief Description of the Service: Branthwaite is an older style adapted and extended home offering accommodation for 21. there are 17 single bedrooms and 2 shared bedrooms. Access is via stairs and a vertical lift. Many of the bedrooms have direct access to the gardens via French doors. There are a variety of day spaces well furnished in a homely style and lounges include designated smoking areas. There are attractive well-maintained gardens, which offer security and privacy for service users. The home is situated in a quiet residential area close to the town facilities of Retford. The home is sited on a main bus route. The current weekly fees are £298 – 334 per week depending upon needs. Hairdressing and chiropody fees are not included. The fees are discussed with prospective service users at the point of enquiry. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place four and three quarter hours and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those service users spoken with were happy with the care received and life within the home. The manager assisted in the inspection process and two other members of staff were spoken with. Staff were able to demonstrate a good understanding of service users needs and promoted a caring atmosphere. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service User Guide has been amended and offers an accurate reflection of the services provided in the home, thus ensuring service users are able to make an informed choice. The registered person now confirms in writing to the service user that the home can meet the assessed needs of individuals ensuring assurance that their needs will be fully met. The registered person ensures that the assessment of the service users needs and their care plans is kept under review, with the involvement and agreement Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 6 of service users and revised when necessary regarding any change of circumstances ensuring that service users needs are fully met. The manager has ceased using any documentation and reference in relation to nursing in the assessment thus ensuring that the services offered are clear to service users. Care plans now contain information as to how the health care needs of service users is being met including the nutritional and psychological needs of service users thus ensuring their needs are fully met. Records for accidents are now kept ensuring service users are further protected. The flooring in the hallway near the lift on the second floor is level and there are no trip hazards in the home such as loose carpets or rugs ensuring service users are further protected. The grab rail in the toilet on the first floor is secured ensuring service users are further protected. The water outlet temperatures in communal bathrooms toilets and service users rooms are regulated to 43 degrees thus ensuring service users are protected. Staff have undergone sufficient training in regards to health and safety and manual handling thus ensuring service users are further protected. The environmental health officer has visited the home and offered necessary feedback in regards to the kitchenette, thus ensuring service users are further protected. Cleaning material and toiletries are now stored securely ensuring service users are further protected. A number of good practice recommendations have also been achieved to ensure service users needs are met and they are further protected. Redecoration and refurbishment has been undertaken in a number of communal areas and service users rooms, thus ensuring a more comfortable environment for service users. What they could do better: Ensure appropriate risk assessments are in place with regards to the safe use of bedrails and lap belts to ensure service users are fully protected. It is recommended that additional documentation is requested from recruitment agencies when obtaining staff via their services to ensure service users are fully protected. It is recommended that the quality assurance systems are further developed to demonstrate that the home is run in the best interest of service users. Branthwaite Care Home DS0000008638.V325001.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. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about where to live. Service users may be assured that their needs will be assessed and met prior to moving into the home. The home does not offer intermediate care services. EVIDENCE: The statement of purpose had been amended to accurately reflect the services provided in the home. These are now available within each service users room. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 10 The manager visits prospective service users in the community and carries out a preadmission assessment prior to service user moving into the home. The preadmission assessment was seen within the plans of care case tracked; these covered the requirements of the standard. There was also evidence that the manager had written to confirm that the service was able to met service users needs. One service user spoken with said that someone had visited them prior to them making a decision to move into the home. Both staff members spoken with were able to confirm that this takes place. The home does not offer intermediate care services. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in an individual plan of care, however further attention is required in regards to risk assessments to ensure service users are fully protected. Service users health care needs are met. Service users are protected by the homes medication policies and procedures. Service users feel they are treated with respect and their right to privacy is upheld. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three service users case files were seen, which showed that service users undergo various assessments such as the activities of daily living, manual handling, pressure area care and nutrition. Information gained forms the plan of care. All highlighted needs had a plan of care in place. Plans of care were organised, personalised and reflected the amount of support each service user needs. In regards to the younger adult, an appropriate plan of care was in place, which demonstrated how they were supported to take responsibility for their life and maintain independence as able. There was evidence seen that plans of care were reviewed on a monthly basis, and following any changes in care this was well documented. There was evidence to show that service users and relatives had been involved in the development of the plan of care. Risk assessments were in place for a number of highlighted risks that individuals may encounter, however in regards to the safe use of bedrails all the required information such as checks and positioning of the bedrail was not available. Service users spoken with said that there needs were fully met. One service user discussed how they take responsibility for certain aspects of their care and how they were supported in doing so. Staff spoken with were able to discuss service users needs and the support they required to ensure needs were fully met. During the lunchtime meal two service users were seen to have lap belts in place whilst in wheelchairs, this was discussed with the manager. No documentation to show consent or risk assessments for entrapment were in place with regards to the safe use of lap belts. There was evidence within service users plans of care to show that the multidisciplinary team and other specialist services are accessed as required. Two service users spoken with said that they could see the doctor whenever they needed. The manager said that a good rapport was held with the district nurses and relevant equipment was accessed as needed. There was evidence of relevant equipment seen during the tour of the home, such as specialist mattresses, cushions, and hoists. Evidence of access to age appropriate services and screening was seen whilst observing plans of care. Within plans of care medication assessments were available to show that this had been discussed with service users and it determined if they wished to partake in their medication arrangements. Medication checked on the day of the inspection against the medication chart corresponded. There were no gaps in administration. All appropriate records such as drugs received and returned and fridge temperatures were seen. An up to date British National Formulary was available so staff can check information for each medication administered. Two members of staff did not sign hand written entries however evidence of the recent pharmacy visit showed that the manager had been seeking advice about this. Staff who administer medication have undergone relevant training, Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 13 evidence of this was seen in staff training files and one member of staff was able to confirm this. The manager said that staff are instructed on ensuring that service users privacy and dignity are maintained. Shared rooms have screening available. Consultations may be carried out in private should it be required. Service users spoken with said that staff were respectful at all times and knocked on their door prior to entering. Staff spoken with were able to discuss how they ensure service users privacy and dignity is maintained at all times. Staff were seen to treat service users with respect and offer care appropriately. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing diet. EVIDENCE: Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 15 Staff offer a range of activities for service users should they wish to partake, these include bingo, reminiscence, quizzes, sing a longs and others. Outside entertainers also visit the home. Service users should they wish are enabled to visit the local town and access facilities. One service user spoken with said that they often go to town and then staff meet them there. Access to day centres is also facilitated as needed. Service users spoken with said that there was enough for them to do and they enjoyed the activities on offer. Staff spoken with were aware of individual needs and abilities and how to support service users as necessary. Holy communion is offered by a local reverend should service users wish to join in, also service users are supported in accessing the local churches should they wish. The manager said that there are no restrictions on visiting, the main door is no longer locked, however it is on an alarm system. Visitors may be received in private and one service user spoken with confirmed this. All service users spoken with said that visitors were made welcome and they may go out with them if they wanted. One service user spoken with discussed the Christmas arrangement they had made to spend time with their family. The manager said that staff are instructed on ensuring that service users rights and choices are maintained during the induction and on an ongoing basis. Service users spoken with said that they were able to make their own choices about how they spend their time and what they do; they said that staff were always kind and respectful. Staff spoken with discussed individuality and ensuring that service users are treated with respect and that their rights were recognised and upheld at all time. A wholesome and appealing diet is on offer to service users and choices are available should they be required. The menu and relevant records were seen to confirm this. The home is supported by the sister home Cherry Holt that is adjacent for provision of some of the food served. The meals are transferred by a hot holding trolley and temperatures are taken prior to serving, records of these were seen. The kitchen was seen to be clean and tidy and records such as fridge and freezer temperatures were seen. Service users spoken with said that food was at a good standard, plentiful and choices were offered. Staff were seen to support service users appropriately during the main meal. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. 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. Service users and relevant others may be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Relevant policies and procedures are in place for dealing with complaints received. Two concerns have been received since the previous inspection; records seen showed these had been dealt with according to policy. A discussion was held with the manager in regards to the referral of complaints/concerns to the protection of vulnerable adults team if required. Staff spoken with were able to discuss how they would deal with complaints if received. All service users spoken with were happy with care received and life within the home. All staff employed have satisfactory Criminal Record Bureau checks in place, two staff spoken with confirmed this and were able to discuss the issues of adult protection, they stated that they had received training in this area. The manager said that staff had received training in this area via the National Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 17 Vocational Qualification (a nationally recognised work and theory based qualification.) or a briefing in house. One service user spoken with said that they felt safe within the home. All service users spoken with said that staff were very kind and respectful towards them. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and generally well-maintained environment. The home is clean pleasant and hygienic. EVIDENCE: Two maintenance people are employed who carry out routine maintenance within the home, records of this were seen. The manager said they are waiting Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 19 for planning permission for the proposed new development, however in the mean time redecoration and refurnishing has taken place. The flooring in the hallway near the lift on the second floor is level and there were no trip hazards evident within the home. The grab rail in the toile ton the first floor is secure. The home was clean pleasant and hygienic. Relevant laundry equipment was in place and hand-washing facilities were available. The downstairs bathroom has been tidied up and is available for service user use. All cleaning products and toiletries are appropriately stored. The Environmental Health Officer recently visited the home; the manager has taken advice in regards to the requirements set at the previous inspection, one requirement was set by the visiting officer, which has been met. The Fire Officer also visited, no requirements were set. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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. Service users needs are met by the number and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes current recruitment policies and practices, however further considerations are recommended. Staff are working towards ensuring they are trained and competent to do their jobs. EVIDENCE: The duty rota seen showed that sufficient staff were available throughout the day. The manager said that she considers the skill mix when preparing the duty rota. Staff spoken with confirmed that there was sufficient staff available Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 21 to meet service users needs. Service users spoken with said that staff were available when needed. An induction programme that follows the skills for carers programme was seen within staff training files. The manger said that all new staff undergo this programme, staff spoken with were able to confirm this. Five members of staff have attained the National Vocational Qualification level three in care, three are working towards this qualification, and five staff members have attained level two. Certificates of these awards were seen in the staff files observed. Staff spoken with also confirmed they had attained these awards. Four staff files were seen. All contained evidence of a satisfactory Criminal Record Bureau Check. Two files seen were for long standing members of staff, therefore current references were not available, the manger said she would insert a character reference. Another file was for an oversees worker, all administration had been carried out by an agency, it was advised that the manager obtain copies of references and relevant documentation from the agency. All other required documentation was available. Staff are working towards ensuring they are trained in all mandatory areas, each member of staff have individual training files where certificates are stored along side supervision records, these were seen. All staff have undertaken training in dementia awareness. The manager said that additional training is to be booked following the festive season to ensure all staff have completed all areas. Staff spoken with said that they felt supported in their development and said that training offered was at a good standard. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A person who is fit to be in charge and of good character runs the home. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 23 Further documentary evidence is required to fully show that the home is run in the best interests of service users. Service users personal finances are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager has been in post for 16 years and is registered with the Commission for Social Care Inspection. She has completed the Registered Managers Award and three dementia awareness courses, and she said she ensures she remains up to date with mandatory training. Staff spoken with spoke highly of the manager and said that she was approachable and supportive at all times. All service users spoken with said that the home was well run. There was evidence of letters and cards received by way of thanks for care received. The manager said that she was always available and spent time on a daily basis talking with service users and relatives. There are questionnaires that service users and relatives may complete and these are located in the main entrance, however none have been returned. Four service users personal finances were checked; these corresponded with the accounting sheet. There were receipts available for necessary transactions; two members of staff or the service users or relative had signed for transactions that had taken place. The manager said she is not responsible for any service users personal finances. One service user spoken with discussed how they go to town and deal with all their own financial affairs. Lockable facilities are available for all service users. Relevant maintenance and servicing certificates such as the electrics, lift, manual handling equipment and waste were seen. Water temperatures are recorded on a monthly basis, as are service users call bells, window restrictors and wheelchairs, these records were seen. Relevant information was recorded in accident records and these showed that appropriate action had been taken; the manager said that she audits these on a regular basis. The fire logbook seen showed that fire alarms are tested on a weekly basis, as are emergency lights. The majority of staff have undertaken a fire drill. Risk assessments on safe working practices were available. Branthwaite Care Home DS0000008638.V325001.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 3 2 X 3 3 4 X 5 X 6 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 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X 37 X 38 3 Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 13(4,c) Requirement Timescale for action 14/02/07 2 OP29 7,9,19 Sch 2 Ensure appropriate risk assessments are in place for the safe use of bedrail and lap belts. Ensure consent has been obtained for the use of lap belts. Ensure all staff files are 14/02/07 available for inspection and contain all items specified by regulation. This has been partly met however when an agency has been used to employ staff additional copies of documentation are to be requested and obtained. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations Further develop the quality assurance monitoring. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Branthwaite Care Home DS0000008638.V325001.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!