Inspection on 28/11/06 for Breme

This inspection was carried out on 28th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Breme 16/12/09

Breme 25/01/06

Breme 28/06/05

Breme 01/02/05

Breme 22/06/04

Breme 26/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Ravenhurst

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

CARE HOMES FOR OLDER PEOPLE Breme 46 Providence Road Bromsgrove Worcestershire B61 8EF Lead Inspector Mrs Yvonne South Unannounced Inspection 28th November 2006 08:45 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 Breme DS0000041841.V314027.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. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breme Address 46 Providence Road Bromsgrove Worcestershire B61 8EF 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) 01527 571320 01527 882218 breme@heart-of-england.co.uk www.heart-of-england.co.uk Heart of England Housing and Care Limited Mrs Karen Keen Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Learning registration, with number disability over 65 years of age (2), Old age, not of places falling within any other category (60), Physical disability over 65 years of age (60) Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 25/01/06 Brief Description of the Service: Breme House is a purpose built 60 bedded home in a residential area of Bromsgrove, which is close to the town centre and is on a bus route. The home offers a service for 60 older people who may have a physical disability and mental health needs associated with older age. Additionally the home is registered for 2 people over the age of 65 who have a learning disability and has a separate 8-bedded unit for people who have dementia. The home is on three floors and all the bedrooms are single and en-suite with toilets and showers. The upstairs rooms can be accessed by passenger lift and there are handrails throughout the building. Separate toilets and bathrooms are adapted for people with physical disabilities. Communal lounge, dining facilities and kitchenettes are provided on all floors and there is an attractive garden. The registered providers for the home are Heart of England Housing and Care Ltd for whom Mr John McCarthy is the responsible individual. Mrs Karen Keen is the home’s registered manager. The pre inspection questionnaire completed and returned to the Commission for Social care Inspection by the registered manager on 26.10.06 states that the charges for accommodation and care at that time were between £1700 and £1920 per month. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The focus was on the key standards. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. Evidence was gathered from information provided to the Commission for Social Care Inspection since the previous inspection which took place on 25/01/06, questionnaires that the Commission for Social Care Inspection asked the home to distributed to residents, relatives and health care professionals and a site visit that took place on 28/11/06 which extended over 10 hours 15 minutes during which the inspector talked to three residents, four relative and five staff, undertook a partial tour of the building and assessed a range of documents. The inspector was assisted principally by the Registered Manager, the Care Services Manager and the Hotel Services Manager. What the service does well: The home provides detailed information for anyone seeking accommodation and care. Full support, opportunities to visit and discuss the service are readily available. The residents receive the personal and health care they need. One relative has commented; The standard of care is very high and this is reflected in my relative’s good health and well being. Opportunities are provided for participation in a range of events in the home and in the community. Local church leaders visit the home and support residents who wish to see them. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 6 Residents are complimentary regarding the food. A choice is always offered and special diets are catered for. They say; The choice of meals is good. Food is fine. Always good. Always a good choice. Residents and relatives are encouraged and supported in expressing any concerns and are confident that they will be listened to. What has improved since the last inspection? 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. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 7 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 Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 8 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): 1,2,3 (standard 6 is not applicable as this service is not offered by the home). Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive all the information and support they need so that they can make a decision regarding their choice of home. The home only offers a service to people whose needs they can meet. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 9 EVIDENCE: The inspector focused on three residents One of these residents remembered that she had received a copy of the Service User’s Guide. She was aware that she had signed a contract and received a copy. She knew she had a copy of the complaint procedure but ‘was not one for filling in forms’. They were all in a drawer in her room she said. Her relative confirmed that they received a letter each year from the home explaining why the fees had risen and by how much. A community care assessment received prior to admission informed the home about the care that was needed. A second resident said that she fell and was then admitted to the home. Her finances were managed by the home and she had no interest in the process or the details. Her relative had no knowledge of the financial arrangements but believed it was done ‘automatically’. The manager was able to confirm that financial arrangement had been put into place by the resident and the social worker that had supported her through the admission. The resident was informed of all financial changes but took no interest. This lady could not recall receiving a ‘visitor’ prior to admission but there was evidence in the file that a pre-admission assessment had been carried out and an initial care plan had been drawn up. Staff could recall undertaking the assessment. The third resident said that she had received a copy of the brochure and the Service Users Guide in the ‘Welcome Pack’. She knew full details of her financial arrangements and had not lived in the home long enough for financial changes to occur. Copies, including a contract, were seen in her room. She knew of the home prior to admission and her needs had been assessed. Documents that were assessed demonstrated that acceptable and informative contracts and terms and conditions were provided for each resident. This was supported by the questionnaire responses received from nine residents. They all confirmed that they had received a contract. A sample of letters was seen that indicated that the resident or their representative was sent information regarding rises in fees and the reasons for the rise. The manager said that all prospective residents and their families were sent a copy of the contract and terms and conditions of residence to consider prior to admission. If time was short the document would be provided on admission. Documentation was always supported by a verbal explanation. People were invited to the home and could visit and discuss their situation as often as they wished to help them make a decision. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 10 Three staff were interviewed by the inspector. They were all aware of the action they would take if inquiries were received about the home. They knew where the Statement of Purpose and Service Users’ Guide were and their purpose. Their roles did not require knowledge of financial details. However they rightly presumed that the managers and administrative staff dealt with such matters, and letters were sent to appropriate people when changes occurred. Three files that were assessed held acceptable pre-admission assessments and care plans. Minor suggestions for improvements were made. A copy of acceptable up to date Statement of Purpose, Service Users’ Guide and Inspection Reports were available in the reception area. The administrator said that a Welcome information pack was sent to anyone who made an inquiry and all new residents. It was seen that this contained full information including a detailed brochure, a copy of the Service Users’ Guide, a blank copy of a contract and terms and conditions of residence, a statement of the current charges, a copy of the home’s newsletter, a copy of the inspection report and a copy of the comments and complaints procedure. Breme DS0000041841.V314027.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, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information and training is provided so that staff provide the personal and health care that the residents need with due regard for their wishes and dignity. EVIDENCE: The records of three residents were assessed. A new care record system had recently been introduced. This made the retrieval of information much easier to obtain. The records were detailed and informative. Needs had been assessed and care plans drawn up in response. The care staff evaluated the care plans daily and the manager monitored the quality and content of the documents monthly. Risk assessments had been undertaken where necessary. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 12 The records provided evidence that health care was being provided by care staff and supported by doctors, district nurses and other health care professionals. The notifications that had been sent to the CSCI demonstrated that the appropriate health care action was being taken when people had accidents or became seriously ill. The manager said that the care plans were reviewed with the resident concerned. It was observed that the residents had signed the facing page of their record but there was little written evidence of further involvement. It was recommended that this be developed. Residents’ questionnaire responses were positive and the following comment was made; I feel happy and cared for. Relatives comments included; They make sure she has her medication, call the doctor when necessary, make sure she sees the dentist and her eyes are tested. They keep me well informed. However one relative said; Overall we are pleased with the care provided. It is only little things that niggle e.g. missing glasses and teeth. Medication was well managed. The staff said that they had received relevant training and their records supported this. Suitable secure storage was provided on each floor and was well maintained. A sample of records was assessed and was well maintained. Managers monitored the ability of staff and undertook frequent checks of documentation and storage. All bedroom, ensuite, bathroom and toilets were fitted with approved locks. Residents were offered the keys to their bedroom doors and lockable storage. This was recorded in their files and confirmed by residents. All residents were able to have a private telephone in the bedroom and could receive calls to the home in private. Mail was delivered unopened and assistance provided if required. Staff demonstrated that they knew how to respect residents’ privacy and dignity and it was observed that their relationship with residents was pleasant and courteous. Training had commenced when they had been appointed to their posts. (Induction training) Care records demonstrated that information was sought regarding culture and religion. This information could be developed further. However one resident confirmed that she participated in services in the home and received regular visits from a Minister and Lay Preacher. End of Life Care wishes had been ascertained and documented. Breme DS0000041841.V314027.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, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Facilities and events are organised so that residents have opportunities to participate in a choice of interesting social events in the home and in the community. Links are maintained with families, friends and faiths. A choice of good quality meals is provided from which residents can make a selection and enjoy nutritional food. EVIDENCE: The pre inspection questionnaire completed by the manager stated that a wide range of activities were provided in the home and supported in the community. Residents’ records provided information regarding their past and present interests and their participation in the home’s events. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 14 Nine residents’ questionnaires were completed. Six people said that there were always activities in which they could take part in if they wished. One person said that there usually was, and two people said that there sometimes was. Comments made included; I enjoy taking part in most activities especially hand massages and pickles (making pickled onions) at Christmas time. Enjoy social afternoons and singalong. I enjoy most activities in the home and take part in most. Would like more evening entertainment. Dependent on District Nurse visits etc. I can always join in but I would like to go out on day trips more. Very good. The inspector spoke to two residents in their rooms and one person in the lounge. They said that they had no complaints and were happy. They recounted the interests and activities that they took part in and appreciated that they were able to use the lounge, dining room and bedroom as and when they wished. They received a weekly copy of the activity programme and a copy was displayed on notice boards. Visitors were always welcome. This was confirmed by relatives, the visitors’ book, residents and observation. A comment in the questionnaire response from one relative stated You get a warm welcome on arrival. Good standard of care for my mother. Residents confirmed that different ministers of religion visited the home and interdenominational services were held for those who wished to attend. Samples of acceptable menus were submitted to the CSCI and the resident questionnaire responses were mostly positive. Comments made included; Nice food at Breme. Very satisfied most of the time. Bit more choice. Residents told the inspector that; The choice of meals was good. Food is fine. Always good. Always have a choice.’ Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have access to the information they need so that they raise issues that concern them. Concerns are then investigated and responded to appropriately Staff are appropriately recruited so that vulnerable people are not put at risk EVIDENCE: The manager and administrator confirmed that all residents and their representatives had received a copy of the complaints procedure in the Service Users’ Guide and ‘Welcome Pack’. Information regarding advocacy was also included and available in the reception area and on the notice boards. Residents who spoke to the inspector could not recall a copy of a complaints procedure. One person said that she expected there was a form but she was not one for filling in forms. However everyone was quite clear what action to take if they were concerned; Tell the staff. Sort it out myself. Go to the authorities. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 16 There was a residents’ representative identified on the notice board. This person made regular contact with the residents and when required spoke on their behalf. The manager stated that complaints and how to raise concerns was a recurrent topic for discussion during residents meetings. These meetings were held every 8 to 12 weeks in each lounge to encourage maximum participation. Annual quality questionnaires were distributed to residents, and concerns and criticisms were followed up and addressed. A quarterly analysis was made of complaints and compliments that had been received by the home so that weaknesses and areas for development could be identified. One complaint had been received by the Commission for Social Care Inspection (CSCI) since the previous inspection. The registered provider had been asked to investigate the concerns. These were that there was difficulty in opening the front door due to a broken lock. It was thought by the complainant that this was a fire exit. However this was not so and the lock was repaired the next day. Comments were also made regarding staffing levels. Checks were made that the levels were able to meet residents’ needs and the subject was raised at the resident’s meeting. They expressed no concerns. The pre inspection questionnaire indicated that the home had responded to three complaints including this one. The records indicated that the other complaints had concerned the lack of representation at a funeral. This had been due to a break in communication and apologies had been made, and a lack of respect by a member of staff. This had been appropriately addressed. Three staff were interviewed by the inspector. One person knew there was a file and forms, and all staff correctly stated that they would refer the complaint/complainant to their senior. Breme DS0000041841.V314027.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, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to live in a comfortable home that suits their wishes and needs. Training, maintenance and systems ensure risks of cross infection are managed. EVIDENCE: A partial tour of the home was conducted. It was observed that residents’ bedrooms had been personalised according to their wishes. Everywhere was clean, well maintained, decorated and furnished. However one relative said in the questionnaire response that the bedroom needs vacuuming more often. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 18 Suitable aids and equipment were provided and staff confirmed that there was sufficient to enable them to assist residents without difficulty. The maintenance record demonstrated that systems and equipment were regularly monitored and serviced to maintain good safe working order. Hygiene was observed to be of a high standard. The residents’ questionnaire responses stated that it was always fresh and clean. One person said that it ‘could not be better’. Staff and their records demonstrated that they had received training in infection control. Personal protective equipment and facilities were appropriately placed. The laundry was observed to be well equipped, and maintained in a clean orderly fashion. Breme DS0000041841.V314027.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient suitable staff are recruited and employed to provide the skilled care that residents need. At times staff appear under pressure but the residents’ care is not compromised. Training is ongoing to ensure staff have the knowledge and skills to provide the care residents need. EVIDENCE: Samples of staff rosters had been submitted to the Commission for Social Care Inspection and these demonstrated that there was a good mix of roles and skills at all times. The pre inspection questionnaire completed by the manager demonstrated that the home employed in excess of the number of staff hours that had been calculated as necessary based on residents’ dependency levels. Documentation demonstrated that the dependency level of residents were constantly monitored to ensure sufficient staff were rostered on duty. However fifty percent of the relatives that returned questionnaires expressed a belief that there was insufficient staff at times. Comments made were; Very often there is a staff shortage. Hot drinks are not always offered outside meal times. Bedrooms need vacuuming more often. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 20 The staff appear kind and caring but sometimes there doesn’t seem enough staff which isn’t fair to residents or staff. We understand the difficulty balancing costs and prices and the fact that getting enough staff may not be easy or too expensive for residents/relatives. Of the nine residents that returned questionnaires four said that staff were always available, four said that they were usually available and one said that they were sometimes available. Two members of staff considered that overall staff levels were ‘OK’ and they had a good team. Sometimes it was necessary for staff to work in different areas of the home to cover the absence of other colleagues. The pre inspection questionnaire stated that 30 of staff were qualified to National Vocational Qualification (NVQ) Level 2 or above. This is twenty percent below the fifty percent required by the National Minimum Standards. However at the time of the fieldwork there were sixteen staff on NVQ courses and when successfully completed the percentage would rise to 58. A full staff training matrix was displayed in the office that demonstrated achievements and training needs. The manager said that this was continuously updated through the year and an annual review and plan was undertaken. Staff that spoke to the inspector appreciated the commitment to training and their records reflected their achievements. The pre inspection questionnaire and records of three staff were assessed. They demonstrated that the individuals had been appropriately recruited. References had been obtained, checks had been undertaken by the Criminal Records Bureau and interviews conducted. The manager said that some residents were actively involved in the recruitment process. The staff confirmed the process they had passed through before being appointed. Since the previous inspection eight staff had resigned and one had retired. There were no staff vacancies at the time the fieldwork was undertaken. The residents and relatives were very complimentary regarding the staff. Comments made included; Very caring staff. I get on very well with the staff. They always listen to me and help me. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 21 Very helpful and tolerant with me as I am forgetful. Excellent. Cannot fault them. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The experienced, well-qualified manager ensures the residents receive the care they need and their health, welfare and wellbeing is safe guarded. The home is managed with due regard for the health and welfare of everyone in it. EVIDENCE: The home is managed by a strong management team that is led by a wellqualified registered manager. Staff and residents described her as; Approachable. Supportive. Always available. Lovely. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 23 The home distributed questionnaires to each long stay resident once a year. Questionnaires were also provided at the first review to be held after admission and after every respite visit. These sought views on the quality of the service the home provided. These views were then responded to where necessary and analysed. The results were used to identify areas where improvements could be made and the service be developed, and they were made available in Welcome packs and the Statement of Purpose and Service Users’ Guide. Residents’ meetings were held every eight to twelve weeks. In addition the care records and medication management were monitored monthly, the complaints and compliments, accident records, equality and diversity were audited quarterly. An independent firm had also been contracted to undertake a quality assurance audit through questionnaires this year. Visits were undertaken each month in accordance with Regulation 26 to inspect the management of the home. There was not a formal quality assurance system as such. However the different elements described above could be drawn together to form one that met the requirements of the home and provider. The management of residents’ personal monies was acceptable. Secure storage and records were well managed. The maintenance records demonstrated that equipment and systems were regularly monitored and serviced. The certificates and the pre-inspection questionnaire endorsed this. The staff training records indicated that they had received training in health and safety subjects and those who spoke to the inspector confirmed this. The fire risk assessment for the home was carried out in April 2004 and the fire safety checks of systems and equipment were acceptable. Staff were receiving training in accordance with the recommendations of the fire authority. Breme DS0000041841.V314027.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 4 4 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 4 X X 4 Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations There should be more evidence of each residents’ involvement in their care planning. Breme DS0000041841.V314027.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Breme DS0000041841.V314027.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!