Inspection on 01/09/06 for Brentry

This inspection was carried out on 1st September 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

Brentry 16/04/09

Brentry 10/04/08

Brentry 25/04/07

Brentry 03/02/06

Brentry 14/07/05

Brentry 16/02/05

Brentry 12/08/04

Brentry 03/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Brentry Knole Lane Brentry Bristol BS10 6QH Lead Inspector Grace Agu Key Unannounced Inspection 09:30 1 September 2006 st 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 Brentry DS0000035568.V295842.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. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brentry Address Knole Lane Brentry Bristol BS10 6QH 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) 0117 9507567 0117 9507575 Bristol City Council Mr Paul David Fuller Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: Brentry House is a care home registered with the Commission for Social Care Inspection in the Older Persons category. It is operated by Bristol City Council Social Services & Health (SS&H) and has 40 beds. The home is arranged over two floors with lift access and has large patio areas to the front and rear of the home. Brentry is largely accessible for disabled older people and their relatives, and continuing work to improve access has been carried out. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which was undertaken over nine hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection four requirements were made in relation to different areas of the service provision at the home. It was noted that the home had met three of the requirements and one was no more relevant due to successful resolution of the identified problem. Residents looked well cared for and were noted interacting with staff in an informal and friendly manner. As a part of this inspection four immediate requirements were made in relation to return of all unwanted medication to the pharmacy and ensuring that all limited life medication are dated from the day of first opening, providing identified resident with a care plan and risk assessment to meet the need and to ensure the identified room is cleaned to eliminate unwanted odour. Seven residents and three staff members and one relative were spoken with at the inspection. A number of records were viewed and a tour of the building was undertaken. What the service does well: Generally the Home was found clean, warm, well lit and partially free from unpleasant odours. The atmosphere of the Home was noted to be relaxed. Residents looked well cared for and staff were noted interacting with residents in an informal respectful and dignified manner. At a discussion, the Manager stated that the Home continues to maintain high standards of care through a ‘resident orientated’ environment. The manager also stated that the home encourages and motivates the residents through dialogue to participate in activities and other entertainment provided at the home. There is an in house shop and bar for the residents. This is open every evening. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 6 Residents and their relatives are encouraged and are well supported to participate in care plan reviews to enable them to feed back on any area of the service that they were not satisfied with. The home ensures that a multidisciplinary approach is followed when necessary in order to maintain good relationship with the doctor’s surgeries, social workers and district nurses. The home operates a handover system on each shift to ensure that staff are updated on each resident and are provided information on any new developments about the home. The manager also stated that the home has a well-experienced management team. Various skills within the team compliment each other to ensure effectiveness in meeting the needs of the residents. The home continues to provide good training for its staff both internally and externally to ensure that the needs of the residents are met. A large percentage of the care staff have achieved the National Vocational Qualification at level 2. What has improved since the last inspection? What they could do better: At this inspection four Immediate Requirements were made. Whilst reviewing medication, some medicine chart discrepancies were noted. The home must ensure that all unwanted medication must be returned to the pharmacy or destroyed as appropriate. Furthermore, all limited life medication (eye drops) must be dated when opened. To minimise the risk of drug error to a resident all medication administered to the resident must be recorded in the Medication Administration Record Sheet. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 7 To ensure that care needs of identified residents are met it would be better to provide appropriate care plans for identified needs and to provide adequate protection, risk assessment must be undertaken following falls of identified residents. Furthermore to ensure that a resident enjoys a comfortable environment the flooring in an identified resident’s bedroom and the ground floor lounge must be deep cleaned or replaced to eliminate unpleasant odour. Prospective residents and their relatives / representatives would be more reassured if the home confirms in writing its ability to meet their needs and ensure that the residents are provided with the terms and conditions of their stay At this inspection evidence from residents’ comments on the day, feedback from the survey and observation showed that insufficient activities are provided at the home. The Manager must address this concern to enable the residents to remain stimulated whilst living in a care home and eliminate the feeling of boredom. Residents would benefit if the home addressed unpleasant odours in the lounge and some of the bedrooms. 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. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The process of admission of prospective residents is comprehensive, detailed and well planned to enable the residents to make a choice of moving to the home. However the home has failed to confirm in writing that it is able to meet prospective residents needs and to issue contracts relating to their stay. EVIDENCE: The residents care files reviewed contained detailed assessment of physical, emotional and social needs before admission to the home. Residents spoken with made satisfactory comments about the home and staff. One relative spoken with confirmed that “ Mum was assessed by a Social worker” before admission to the home and that they visited the home to enable them to make an informed choice before their relative moved in. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 10 Whilst there was no contract seen in the files viewed and evidence from the survey completed by the residents showed that eleven of the fifteen have not received a contract, the relative confirmed that they were given a contract to sign and that the individual had a one-month trial period. However, no confirmation letter of meeting needs was given to them none was noted in any of the files viewed. It was agreed that the home would provide prospective residents with a written confirmation that their needs will be met in respect of health and welfare after assessment. All residents must be provided with contract to ensure that they are aware of the terms and conditions of their stay, Staff spoken with demonstrated understanding of the needs of the resident. Brentry DS0000035568.V295842.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed and are respected. Doctors and other health professionals are involved in their care; however, the care planning and medication administration procedures fail to offer protection to the residents. EVIDENCE: Three care files were reviewed at this visit. All the care files contained pre admission assessment to determine how the home was to meet the needs of the residents. The care files viewed included those of two of the most recently admitted residents. One care file reviewed had no care plan in relation to identified need (memory loss) to ensure that staff are aware of how to adequately meet the need. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 12 It was also noted that another resident with poor nutrition and identified weight loss who was seen by the General Practitioner (GP) on four occasions had no care plan on how the need was being met. There was no evidence that the weight was being monitored, On one occasion the individual was put on a food supplement. Whilst the person was seen by the GP on those occasions there was no evidence of referral to the dietician for further management. At a discussion with the individual’s relative, the person stated that they were aware and concerned about the weight loss and had raised concerns with the manager. It was also noted that this individual had no care plan in relation to challenging behavior following recorded entries on 21/8/06 “kicking and hitting” and on 23/08/06 “ hitting out”. The daily report made no reference to how this need was being met. These were followed up with an immediate requirement to ensure complaince in order to meet the needs of theresidents. The other care plans were relevant to the assessed needs and were backed up with a range of assessments. The daily report seen on those care files were detailed and contained information of care provided. The inspector was concerned about the numbers of recorded accidents to residents over a period of four months before the inspection. The incidences were discussed with the manager. There was evidence that two of the residents had been discharged to a more appropriate setting, two residents had passed away. One resident had no risk assessment following a fall on 15/5/06. An immediate requirement was made to remedy the situation and to ensure that the residents are adequately protected. In regard to how residents perceive their care at the home, one resident stated, “ I like it here, I would not like to be anywhere else, staff look after me well, I get up when I like and I go to bed when I like everybody is nice and understanding”. Another resident stated, “staff are very kind, I am partially sighted and staff help me to write out birthday cards”. One resident stated staff “respect me and always make sure that the door is closed when I am bathing or using the toilet”. Staff were noted knocking on the doors before going in to the residents rooms to assist them with personal care. Residents are empowered to make choices about their personal care, however sometimes their choice of staff may not be met due to availability of the preferred staff member. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 13 The care files viewed had evidence of visits from the health professionals to include General Practitioners (GP) Chiropodists, Opticians and Dentists. The procedure for the administration, storage and disposal of medication was reviewed and was noted to be unsatisfactory. It was disappointing to note whilst reviewing medication that a large stock of a discontinued analgesia was stored in the cupboard. The Deputy Manager stated that the doctor had recently reviewed the resident’s medication. Whilst the recently prescribed analgesia was recorded on the Medication Administration Record Sheets (MARS), staff continued to administer and sign for the discontinued analgesia that was not deleted from the MARS. This practice puts the resident at risk of drug error. Furthermore, limited life medicine (Eye Drops) had no date of opening to ensure that it was discarded when out of date. An immediate requirement was made to ensure that the medication malpractices were remedied. Response to the immediate requirement including action to be taken to remedy the discrepancies noted was received at the Commission For Social Care Inspection within the time-scale given. One Staff member spoken with was aware of measures to be taken if a resident became terminally ill and in the event of death. The staff also demonstrated awareness of the importance of ensuring that information about residents is kept confidential. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to maintain links with their families; they are also provided nutritious meals however meaningful activities for the residents must improve. EVIDENCE: On the day of inspection residents were noted relaxing in the lounge and enjoying the company of each other, some residents were noted sitting in their bedrooms other residents were also observed accessing different areas of the home without restriction. At a discussion with some of the residents met in the lounge, both stated that they are happy at the home; they get up when they wanted to and retire to bed when they wanted to and that staff treated them with respect. One resident met in their bedroom stated that they were not always provided with their favourite staff to assist them with bathing; however, he was satisfied with the care provided at the home. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 15 The manager stated that the residents are provided with a range of activities to include reminiscence afternoon, bingo, film show and video. There is a shop and a bar in house that is open every evening. The manager stated that the planned activities for the residents this autumn include a trip to Blaise Castle, traditional fish and chips supper form the shops and a Barbecue before October. Review of the care files evidenced that the home operates a key working system and the key workers encourage residents to participate in activities provided and ensures that these are recorded in a section of the care file. One resident spoken with stated, “I go out and walk round to chat to people. I go to art class every Tuesday, I go out to see a friend once a week and go out with my family once a week” However, the general feeling of the residents on the day was different. A sample of the residents’ opinion regarding activities was that the home provided them with little or no meaningful activities. One resident stated, “ There is nothing to do, not much activities”. A group of residents met in the lounge stated “we do nothing all day” Another resident stated “No activities, we sit here all day doing nothing” Another resident stated “we have asked to go on a trip to Weston but nothing has happened”. Compilation of the evidence from the residents survey in relation to activities showed that eleven of fifteen surveys received stated the there are never activities in the home. It was also disappointing to note that on the day residents were noted sitting in the lounges and some in their rooms with little or no activities to stimulate them. This was discussed with the manager at feedback and a requirement was made for the home to develop a more structured activities programme after consultation with the residents to ensure that the feeling of boredom expressed by the residents is eliminated. The visitors’ book showed that the relatives and representatives regularly visit the residents. Residents spoken with stated that they had regular visitors. One resident stated, “My sister comes on weekends.” Another resident stated, “My son visits when he can”. One relative met on the day stated that they visit the home every other day and sometimes they are made welcome. The lunch on the day looked nutritious and balanced and the residents spoken with stated that they enjoyed their meal. The kitchen was found clean and staff have attended basic food hygiene to ensure that the residents are adequately protected. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are protected from abuse. EVIDENCE: The home has appropriate procedures in place for the management of any complaint at the home. There were no recently recorded complaints and no complaints had been received at the Commission for Social Care inspection. There is evidence that staff have attended Protection of Vulnerable Adults from abuse training and has a Protection of Vulnerable Adults policy; there was evidence of the Bristol City Council document on how to report incidents of suspected abuse. The manager demonstrated knowledge of the procedure for reporting incidents of abuse if they occur. Staff are aware of the Whistle Blowing Policy and are able to report incidents of abuse without fear of reprisal. There was a recorded complaint in January 2006 regarding missing money, it was noted that appropriate procedure was followed and the resident declined to allow the home to take further action. The other two recorded complaints were satisfactorily resolved. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 17 Residents spoken with and responses noted on the comment card evidenced that residents are aware of whom to complain to. One resident stated, “I have no reason to complain”. One resident stated that they are aware of their rights and were enabled to vote using the postal voting system. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents enjoy a suitable, safe environment, however, the home fails to provide them with a comfortable and unpleasant odour free environment. EVIDENCE: No changes had occurred in relation to the home’s suitability for its stated purpose on the provision of care for the residents. The residents were found sitting in the communal areas and appeared relaxed in their homely environment. The home was found clean, warm and well lit. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 19 Whilst the home was found to be generally clean it was noted that the ground floor lounge flooring was heavily stained and needed to be deep cleaned or replaced. It was also noted to have an unpleasant smells. Whilst touring the building two residents rooms were noted to have unpleasant odours. The manager stated that the flooring had been deep cleaned regularly. The home would consider alternative flooring. A requirement had been made to deal with this issue to ensure that the residents are provided with a comfortable environment. Hand and grab rails were noted in the corridors and bathrooms to aid residents’ mobility One resident spoken with stated, “The Home is very good”. Another resident spoken with stated that they felt safe at the home. The laundry area was found clean and tidy. Housekeeping staff have attended courses on Control of Substances Hazardous to Health (COSHH). Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with sufficient numbers of staff to meet their needs, adequate training is also provided to staff to protect the residents. EVIDENCE: On the day of the inspection there were thirty-four residents at the Home. Evidence from the staff rota and discussion with the Assistant manager showed that the home has a sufficient staffing level to meet the needs of the residents. Whilst reviewing the rota, inconsistency was noted in the number of care staff on late shift during the week and on weekends. The rota showed four care staff on late shift on weekdays and three care staff on late shift on weekends. It was not clear why this is the case considering that the number of residents remains the same. The manager needs to review the staffing level on those shifts to ensure that the residents’ needs are adequately met and to address a resident’s comment about the weekend staffing level “Not enough staff on weekends”. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 21 Residents spoken with stated that staff attended to them promptly when they rang the bell and provided time for them to talk. The Home operates a key working system to enhance the resident/staff relationship. Staff training records showed that the home invests in the training of its staff to ensure that staff are aware of their roles and responsibilities and that a high standard of care is maintained. Records showed that staff have attended training on manual handling, fire updates and other relevant courses. Evidence from the most recently employed staff files showed that an appropriate recruitment procedure was followed and the personal files viewed at the home contained documentation in relation to induction training and supervision. The manager stated that application forms, references and Criminal Record Bureau disclosures are stored at the Head Office. Records also showed that staff have received comprehensive induction training prior to attending to residents’ personal care independently. Brentry DS0000035568.V295842.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed; Residents are generally protected through appropriate health and safety practices. EVIDENCE: Mr Paul Fuller, the Registered Manager is a qualified nurse and a qualified social worker and possesses a Certificate in Management Studies. Mr Fuller is a National Vocational Qualification Assessor and has attended a course on mental health. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 23 On the day of inspection, there was evidence of a friendly and interactive atmosphere in the home. Residents looked well cared for and staff were noted interacting with the residents in an informal, dignified and respectful manner. The manager was unavoidably absent in the morning on the day however, two senior staff members met on the day showed satisfactory leadership qualities and assisted professionally with the smooth running of the home and the inspection process before the arrival of the manager. Staff spoken with stated that staff work as a team and that the Manager and the senior management team enable them to provide quality care to support the residents. Another stated that the manager is good and that he is approachable and would listen to any concern raised. Residents spoken with made positive comments about the Manager. One resident stated,” the manager is good, he always has a joke with you”. A group of residents met in the lounge stated, “Paul is very good”. Staff supervision records were reviewed. Evidence from the records viewed showed that staff had received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the exercise The fire log book was noted to be up to date. Staff have attended fire awareness training and regulare fire drills. Generic risk assessments of different areas of the home were noted in place. Other health and safety checks as well as the maintainace book were up to date. The accident book showed a high recorded number of accidents to four individuals between February and May 2006. One individual had three recorded falls . The individual had a care plan in relation to poor mobility, the other residents had one recorded fall each. There was no risk assessment noted in the files to minimise the accidents to the residents. The manager stated that the high number of accidents was due to increasing frailty of the residents and that the home enables the residents to be as mobile as practically possible. The home would raise staff awareness in relation to accidents and would liase with the doctors and other relevant health professionals to find a balance between maintaing independence and providing care intervention. It was agreed that there must be a risk assessment in place for the residents and that this must be regularly reviewed and following the falls. A requirement was made to ensure that this happens in order to protect the residents Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 24 At a discussion to assess how the home monitors the quality of its services, the inspector was informed that the Council commissions an independent survey annually to to gather information from residents, relatives health professionals and visitors about how they rate the services provided. This has recently been completed, however, the manager is not sure of the outcome. Feedback from last year’s survey was good. Other ways used to audit the service include the provider’s monthly visits, reviewing the Care plans monthly. Staff meetings and resident/ relative meetings provide a forum for discussion in relation to service improvement. Issues discussed include documentation, use of agency staff and sick leave. The management of the home meets after the general staff meeting to discuss the issues highlighted and to draw up an action plan on how to address them. The manager stated that the home has an excellent relationship with the GPs, district nurses, and psychiatrics and in reach team. There is also a high occupancy level and there was always good feed back from the residents and relatives after a trial period. The home has policies and procedures to include recruitment and selection, supervision, restraint and Protection of Vulnerable Adults from Abuse. Other residents’ information was noted securely locked away. Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X 3 X 2 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 3 2 Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13.2 Requirement The registered person must ensure that staff adhere to medication policy and procedures when administering medication. Deep clean or replace the carpets identified in the ground floor lounge. Develop a programme of activities that meets the needs of the residents. Ensure that an identified resident’s room is free from unpleasant odour. Provide and review risk assessments to residents following falls. Confirm in writing to the resident the home’s ability to meet their needs and provide them with Terms and Conditions of their stay. Provide a care plan for identified resident’s specific needs. Timescale for action 08/09/06 2 .3 4 5 6 OP27 23 (2) (b) 16 16 13 14 08/10/06 01/12/06 08/09/06 08/09/06 01/10/06 OP12 OP24 OP38 OP4 7 OP8 15 08/09/06 Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brentry DS0000035568.V295842.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!