Inspection on 25/04/07 for Branwell Lodge Nursing Home

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Branwell Lodge Nursing Home 04/06/09

Branwell Lodge Nursing Home 09/10/08

Branwell Lodge Nursing Home 22/04/08

Branwell Lodge Nursing Home 16/05/06

Branwell Lodge Nursing Home 20/10/05

Branwell Lodge Nursing Home 24/01/05

Branwell Lodge Nursing Home 15/09/04

Branwell Lodge Nursing Home 28/06/04

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

CARE HOME ADULTS 18-65 Branwell Lodge Nursing Home Smith Road Off Southfield Lane Bradford West Yorkshire BD7 3NJ Lead Inspector Linda Trenouth Key Unannounced Inspection 25th April 2007 09:30 Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 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 Branwell Lodge Nursing Home DS0000019900.V333851.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 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. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Branwell Lodge Nursing Home Address Smith Road Off Southfield Lane Bradford West Yorkshire BD7 3NJ 01274 521731 01274 523279 wendy.rushworth@bdct.nhs.uk 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) Brunel & Family Housing Association Limited Wendy Rushworth Care Home 22 Category(ies) of Learning disability (22) registration, with number of places Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 Brief Description of the Service: Branwell Lodge is a 20 bedded registered care home providing nursing care for people with varying degrees of learning disabilities and challenging behaviour situated approximately 3 miles from Bradford city centre. The shops and local community facilities are within walking distance. The home is a purpose built property originally registered in 1980. There are pleasant gardens with patio area and ample car parking space. The accommodation compromises of eight flats with single bedrooms, communal living/ kitchen areas, and bathrooms. The manager Wendy Rushworth has recently been approved for registration with the CSCI. Brunel Support Works, who are responsible for the ancillary staff at the home and general maintenance, have been merged with Yorkshire Housing Association. The Bradford District Community Health Trust provides all care and nursing staff. The fees at the home range from £400 to £450.00 with additional charges for toiletries, outings, hairdressing, and the minibus. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I visited the home unannounced and stayed for approximately 7.5 hours. The inspection also included gathering information and evidence before and after the visit to decide the overall judgement. I met with people living in the home and spoke with the manager and staff. During the visit I looked at the records, watched staff working, and talked to people living and working at Branwell Lodge. I also looked around the building. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care. I sent comment cards to people living at the home, relatives, visitors, and social and health care professionals, to give them the opportunity to comment on the service. Feedback from the questionnaires returned is included in this report. I talked to the manager about the outcomes of the visit at the end of the inspection. Requirements and recommendations made during this visit, and those outstanding from previous inspections can be found at the end of the report. What the service does well: The management of the home make sure that staff complete all the necessary training making sure the way in which they care is safe. The food at the home is good and the manager and the staff make sure that the menu is planned in such away that helps everyone have a more balanced and healthier diet, whilst still supporting individual choices. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 6 Relatives felt that the staff are friendly and helpful and that the home is always clean and warm. People knew who to talk to if they had a concern or a complaint, residents and relatives meetings also gave people a chance to have their say in decision making in the home. What has improved since the last inspection? Written information about the home is in a format that is easily understood by the people living at the home and copies of the “service user guide” have now been given to everyone. This information tells people what the home will provide for them while they live there. Care plans have become more person centred, this means that they look at the individual needs of the person. The care plans now look at the social needs and aspirations of a person whilst also looking at all their health care needs. This helps staff plan and provide for all the needs of people living at the home. The way in which the home is repaired and maintained has begun to improve, making sure that people live in a home that is safe and comfortable. Staff have attended training in adult protection and the way in which they protect people from abuse is discussed at staff supervision and meetings in order to make sure that the people are safe and protected from harm. Staffing levels have increased through the night from two to three staff, this is to make sure that people are safe and well cared for at all times of the day and night. A new manager has been appointed and registered with the CSCI, she brings to the home many years of experience and knowledge of the people with learning disabilities. There has also been the appointment of a second deputy manager at the home, improving the support for the manager. This will benefit the people who live and work at the home and give relatives greater confidence in the way the home will be run. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 3,4 and 5. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The service users guide is easy to understand and gives people the information they need to make an informed choice about the home. There is little evidence to show that people are properly assessed before moving into the home, which may mean that their needs cannot be fully met. Contracts between the home and the individual are not signed appropriately and people may not be aware of their rights whilst living at the home. EVIDENCE: The service user guide has been updated and given to people who live at the home and their relatives or representatives. This guide helps inform people of the service that is provided and their specific rights and responsibilities. Whilst one person confirmed they felt they were given the choice to the live at the home there is no evidence of a pre-admission assessment or information to show that people had been given a choice about moving in. There is no evidence that management had been sure that they could meet the needs of the prospective admission. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 10 All prospective admissions must be fully assessed before they move in and documented evidence of the assessment must be available. This will demonstrate that individuals have some choice in the placement and that Branwell Lodge can best meet their needs. People who do not have a carer or family to help them should be helped to find support from a representative or advocate. Contracts are available at the home but the staff themselves have written the signatures of people living at the home. Contracts between the home and the individual must be signed, however the manager must make sure that the individual has appropriate support to understand their rights and responsibilities. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and9. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The care planning and risk assessments have improved but the staff must make sure that people’s individual choices and consent are included. EVIDENCE: Care plans are in place for everyone living at the home and cover all aspects of their health and general welfare. Care plans also need to include assessments and clarify when individuals make choices. Areas such as consent to the administration of medicines and access to their bedrooms at night should be recorded. It is appreciated that all these areas are to keep individuals safe, but they, or their representative, should always be involved in the decision making in areas that affect their personal liberties. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 12 The respect for a person’s privacy is important, including the freedom to come and go as they wish and to have their own door key. I was informed that one person does use a key for their room, which is good practice. Privacy may have to be limited for a person’s safety. If a person is not considered safe to manage his or her own key this should be recorded within their care plan. There are examples however of good practice where specific areas of concern are identified i.e. Epilepsy and sight problems, the use of audio monitors are risked assessed and agreed. This has shown that the staff are protecting people’s rights where their personal liberties are restricted. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16 and 17. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The people who live at the home do not have enough opportunities to experience and enjoy fulfilling lives both within and outside the home. Healthy eating is promoted but could be better communicated by the use of pictures and images on the menu display. EVIDENCE: In the service user guide the home own states it aims, “ To encourage and provide group activities, that are stimulating to promote social interaction, and to provide the service user with a sense of belonging in the community in which they live.” I spoke to staff who said that the extent to which people are involved in the local community is limited but they do visit local parks, pubs and shops. One Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 14 holiday has been recently organised for four people to Cornwall. Not all people wish to go on a holiday but there are other people at the home who are not given that opportunity. I talked to the manager who said that a minibus is available for the people in the home to use. This is however dependent on available drivers and staffing levels. The staff manage some difficult and at times challenging behaviour. Each person is assessed as needing two members of staff to care for them safely. There are usually only 6 staff working during the day, which limits the opportunity for activities. Some individuals are able to occupy themselves and a few attend some day services. The majority of people at the home however rely on the manager and staff to make sure they have sufficient activities and mental stimulation for their well being. Some individuals participate in some small domestic chores but there are no individual planned programmes for personal development or activity consistently provided for people living at the home. Although I saw staff spending time with people living at the home caring and observing those at risk, there was no structure to the day. There is no activities organiser at the home and staff are responsible for any activities. Relatives also raised concerns about the lack of activities in their recent meeting. The staffing levels must be increased to meet the needs of all the people living at the home. The teatime meal was observed during the visit. The meal in the dining room was relaxed and people looked comfortable. Staff sat with the residents for their own meal. Those people who wish to eat in their own flats are helped to do so. The manager said they had changed the menus in order to promote healthy eating. A board in the dining room was up to date with the menu of the day displayed but no alternative or choice was displayed and the written menu could not be understood by many people who live in the home. Although staff said that choice was always available this was not recorded in the menu. It is recommended that alternative choice should be included in the menus and on the displayed board. It is also recommended that a pictorial or image based menu be provided to communicate the choice to more people at the home. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 15 Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People have support to make sure they remain in good health. Medicines are stored and administered safely making sure that peoples’ health needs are safely met. EVIDENCE: Care plans provide the information for staff about the how people wished to be supported. The care plan information sets out the routine and likes and dislikes of those who cannot easily communicate. Specialist support was also referred to in care plans. I spoke to the staff and it was evident that health care is promoted. Health is monitored and the records showed regular contact with GP, optician, audiologist, and other health specialists. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 17 Visiting health professionals spoken to felt that people at the home had good support and healthcare. The medication system and administration was reviewed and found to comply with up to date guidance for care homes. The medication records are properly completed. Only those staff trained administer medication. All medication storage seen was safe and met the required safety standard. Staff have easy access to guidelines and reference books such as the British National Formula (BNF) to make sure they are fully informed when they are responsible for medication in the home. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The people living at the home and their families are made aware of their right to raise concerns or complain. The manager acts promptly to protect people living and working at the home from harassment or abuse. EVIDENCE: The service users guide and additional information includes the complaints process and procedures. There are also resident forums and relatives meetings held by the manager and staff at the home. This gives good opportunities for people to participate in decision making in the home. The home has adult protection and ‘whistle-blowing’ policies and procedures in place that cover the way any concerns or allegations of abuse or poor practice would be handled. Protection of Vulnerable Adults training has been undertaken by most staff at the home and is included in the induction training for new staff. There has been an adult protection issue at the home and appropriate action has been taken to make sure that people are safe at the home. The adult protection team and police are involved with the ongoing enquires. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 19 Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The programme of refurbishment has been started and some improvements have been made. There are two bedrooms in use that do not meet the basic standard and should not be in use as they do not provide sufficient facilities for people using them. EVIDENCE: I raised concerns about the use of two bedrooms in flat 6 and 7, which fail to meet the basic standard for the people living there. The rooms had previously been discussed and agreed would not be used as bedrooms. They do not have sufficient levels of natural light and the windows are too high in the room and overlook the roof space, this meant that people could not see out of their rooms and had no reasonable view. These rooms must not be used as bedrooms because all individuals should have a good standard of bedroom. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 21 The building comprises ground and first floor and is divided into eight flats, six have three beds, and two flats have two beds. Each has a lounge/dining room and a bathroom. A communal lounge/dining room is adjacent to the main kitchen and there is access to an enclosed garden. There are digital locks fitted to the main door, this is to safeguard people within the unit. Decoration and upgrading is still on going. Staff confirmed that despite requests there are still long waits for work to be completed. A staff office has been introduced into the area of the home called the “Priestley Wing” and the manager said that the Snoozelan area might be converted to accommodate staff needs. The manager agreed however that further consultation with the people who live at the home, relatives, and staff is needed. There is a lack of space for staff to carry out their administrative work, the manager has put a proposal in for an office extension, which is in the schedule for the next financial year. The cleaning staff have left and agency staff cleaning are used. The level of cleanliness seen was satisfactory. Those staff I saw followed infection control guidance by washing their hands, using aprons and appropriate clinical waste disposal. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People who use the service experience adequate outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The level of staffing severely restricts the ability of the service to deliver person centred support. There is a high turn over of staff and staff morale is low, concerns have been raised about the continuity and support to individuals living at the home. EVIDENCE: A copy of the rota was available for the week of the inspection and the home appears to be staffed to a minimum but the feedback from staff and relatives was that they have some concerns about staffing levels. One person remains in their flat all day and others like to spend time in their rooms but still have to be monitored because of risks. Staff said there was not enough staff to monitor all residents independently. The service must review their staffing levels to safely meet everyone’s needs. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 23 I spoke to staff who felt that morale was low and they are not clear about the direction the home was going in. Some staff are being transferred because they could not safely meet the needs of people with challenging behaviour. This is after many years of working in the home. Other staff had chosen to transfer to other homes. This has left some of the remaining staff demoralised. There is a high turn over of staff and concerns have been raised about the continuity and support provided to individuals living at the home. New staff are being recruited but staff are concerned how these changes will affect the people living at the home. Relatives too commented that they are concerned about so many staff changes and the effect this may have on the people living there. The staff files seen confirmed that safe recruitment is being undertaken with the nursing and care staff at the home. The manager must be vigilant however that all information is shared regarding future recruitment of staff from Brunel Support Works. This is for ancillary staff at the home. One record reviewed had no references or CRB (Criminal Record Check) on file. The manager had not received this information before the employee began working at the home. The manager has a responsibility to make sure that all staff and volunteers who work at Branwell Lodge are safe to do so. Staff confirmed that induction training is provided, which is followed by the foundation training in learning disabilities. Staff complete LDAF (Learning Disabilities Award Framework) foundation training and then go on to the National Vocational Qualification (NVQ) training. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 and 43. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is going through a period of significant change that affects the consistency and delivery of care. There is a responsible approach to health and safety in the home, making sure that everyone who lives, works, and visits the home is safe. EVIDENCE: The new manager at the home has questioned what the service aims to provide for people living at the home. Presently the home defines itself as providing care for people with varying levels of learning disability and Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 25 challenging behaviour. The manager feels that some people are wrongly placed at the home and their needs could be better met by other services. The new manager is suitably qualified and has enough experience to manage the home well. There is a newly appointed deputy manager, completing a strong senior team at the home to help lead and manage change. The pre-inspection questionnaire confirmed that health and safety checks and tests are carried out regularly, either by the home’s staff or external contractors, making sure the home is safe. I reviewed the following records; fire safety, gas safety, lift certificates, and the electrical contractors had visited the home to test the hard wiring in the last week. The fire system is tested weekly and fire drills are regularly undertaken. The manager had produced a maintenance plan to monitor and make sure all the maintenance and improvements are promptly carried out. The manager has made sure that staff are regularly supervised, staff meetings, residents forums and relatives meetings are held. This helps everyone feel they have a say in the decision making in the home. The home has regular visits from Brunel Support Works who monitor the home’s progress and produce a report, a copy of which is made available to the CSCI. There is however no formal assessment in place to obtain views of relatives, carers, or other stakeholders in the care of the residents in the home. The service must conduct an annual survey and this must include a survey of the residents and their families along with the social and healthcare professionals and any other stakeholders. This should be through anonymous satisfaction questionnaires and the findings should be published and used to inform future planning. This is to confirm that the home is providing a good standard of care and meeting its own aims and objectives. Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 CONCERNS AND COMPLAINTS Standard No Score 22 23 3 2 2 3 2 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x ENVIRONMENT Standard No Score 24 2 25 2 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000019900.V333851.R01.S.doc LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 x 16 x 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Branwell Lodge Nursing Home Score 3 3 3 x 3 3 2 x x 3 3 Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001, and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement All people must have a full assessment prior being admitted to the home to make sure the home can fully meet their needs and they have been supported in their choice. All people must have a contract, which must be signed by them (if able and can consent) or be signed by their representative or relative. Consent to the administration of medication and monitoring at night should be recorded in peoples’ care plans to show they have consented and agreed to this. All people must be provided with a choice of fulfilling activities and supported to enjoy the full range of opportunities and activities in the community. Previous requirement not met 30/06/06 The registered person must make sure that the alternative choice of menu is included in menus and displayed on the board. Previous requirement DS0000019900.V333851.R01.S.doc Timescale for action 25/07/07 2 YA5 5 25/07/07 3 YA6 SCH 3 25/07/07 4. YA12 16 25/07/07 5. YA17 3 25/10/07 Branwell Lodge Nursing Home Version 5.2 Page 28 not met 30/06/06 6 YA33 18 Staffing levels must be reviewed to make sure that there are sufficient staff on duty to meet the needs of people using the service at all times. Previous requirement not met 15/07.06 25/07/07 7. YA25 23 8 YA28 35 9. YA39 35 The registered person must 25/07/07 make sure that the two rooms that do not meet the standard are not used as bedrooms. The “Snoozelan”, facility must 25/07/07 not be withdrawn until adequate consultation has been made with people living at the home, staff, and relatives to make sure the facility is not withdrawn to the detriment of the people living at the home. The service must conduct an 25/10/07 annual survey of the service and this must include a survey of the residents and their families along with the social and healthcare professionals and any other stakeholders. This is to confirm that the home is providing a good standard of care and meeting its own aims and objectives. 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 YA17 Good Practice Recommendations The menus should be displayed in images to make them easier for all people to understand. DS0000019900.V333851.R01.S.doc Version 5.2 Page 29 Branwell Lodge Nursing Home Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Branwell Lodge Nursing Home DS0000019900.V333851.R01.S.doc Version 5.2 Page 31 - 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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