Inspection on 18/10/06 for Brett Vale Residential Homes Ltd

This inspection was carried out on 18th October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brett Vale Residential Homes Ltd 13/10/08

Brett Vale Residential Homes Ltd 27/02/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Brett Vale Residential Homes Ltd Granary Barn, Sulley`s Farm Lower Raydon, Hadleigh Ipswich Suffolk IP7 5QQ Lead Inspector Claire Hutton Unannounced Inspection 18th October 2006 10:30 Brett Vale Residential Homes Ltd DS0000066414.V314666.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 Brett Vale Residential Homes Ltd DS0000066414.V314666.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. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brett Vale Residential Homes Ltd Address Granary Barn, Sulley`s Farm Lower Raydon, Hadleigh Ipswich Suffolk IP7 5QQ 01473 827497 01473 822785 bodjawah@aol.com 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) Brett Vale Residential Homes Limited Mr Vincent Bodjawah Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27th February 2006 Brief Description of the Service: Brett Vale is a privately owned care home providing personal care and accommodation to nine younger adults with learning disabilities. The Home’s statement of purpose gives emphasis to caring for people with challenging behaviours. Brett Vale provides accommodation within a barn conversion and is located in a rural area, close to the village of Raydon, southeast of Hadleigh. Accommodation is all in single bedrooms, seven of which have en suite facilities. There are a number of communal rooms, including a recreation room, and extensive grounds available to service users. Fees for this service range from £750 to £1850 per week. Brett Vale Residential Homes Ltd DS0000066414.V314666.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 key inspection that focused upon the core standards relating to Adults (18 – 65). It took place on a weekday lasting seven hours. The process included a tour of the building and grounds, discussions with residents and staff, observations of staff and service user interaction, and the examination of a number of documents including residents care plans, medication records, the staff rota, recruitment, training records and records relating to health and safety. The report has been written using accumulated evidence gathered before and during the inspection. One completed comment card was received back from relatives/visitors this was complimentary. Five comment cards were received back from the staff group. All of which were positive in their responses. Eight completed resident surveys were received back from the current resident group. These too were positive. Throughout the afternoon the inspector met most of the residents, most of whom were able to express themselves and talk about what it was like to live at Brett Vale. Patrick Mc Donagh (Expert by Experience) and his supporter from ‘Barking and Dagenham centre for Independent Living Consortium’ were there for part of the inspection. As a service user Patrick has an expert opinion on what it is like to receive services for people who have a learning disability. Patrick’s comments are included throughout this report where he is referred to as ‘Expert by Experience’. What the service does well: There are care plans in place for all residents that are known and used by care staff. The recording in these is relevant and shows respect for the residents. The Expert by Experience said “everyone gets on well with everyone else living at the home and said everyone has a key to his or her rooms”. Residents are able to lead an individual lifestyle and opportunities are presented. The Expert by Experience said “Some of the residents go to the pub. Everyone has the choice to go swimming on Fridays. They could all use the games room, which has a pool table. They grow cucumbers, cabbages, carrots and rhubarb in the garden with the help of the staff. They have been growing pumpkins for Halloween”. Staff talk calmly to residents and try to find out what they want. Staff treat residents as individuals. Access to health care is good. One resident told the Expert by Experience “ I really like living at Granary Barn”. The environment is comfortable, well maintained and nicely decorated and continues to meet the needs of the residents. The Expert by Experience Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 6 thought the lounge was very nice and big. The dinning room was being decorated when we were at the home. Staffing levels, recruitment, training and supervision of staff were all good. The expert by experience reported that a resident had said “the staff treated people fairly. All the staff were polite, and the resident told us there were three staff on duty during the day.” 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. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 7 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 Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good. Sufficient information is available for prospective service users to decide whether the home will meet their needs. Current residents individual aspirations and needs are assessed. EVIDENCE: At the last inspection at the home the Statement of Purpose was examined. It contained all the items of information required by Schedule 1 of the Regulations. This document has not been revised since that date, therefore remains valid. The home has a Service Users Guide that was available for inspection and was in each residents care plan file. The service users’ guide includes a copy of the contract with each resident. This covers in detail the financial and staffing support that the home gives to residents who go away on holiday, and which costs fall to the resident to pay. Staff believed that this document had been explained to each of the residents. At the last inspection a repeat requirement was made, as the standard requires that the views of service users obtained from surveys should be included. This had yet to be actioned. Residents were said to have been surveyed in February 2006. Surveys were seen in individual files. The manager agreed to collate this information and include it in the Service Users Guide. No new service users have been admitted to the home for some time. However there was evidence that the needs and aspirations of the current resident group are assessed and form the ongoing regularly reviewed care plan. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is good. Residents, and their representatives can be confident that the plans of care maintained at the home reflect and address the individual and changing needs and aspirations of the person concerned. Individual support and choices are positively promoted from staff. Residents are supported to take risks within a risk assessment framework. EVIDENCE: There was a care plan in place for all residents and these were regularly reviewed. The care plans were of sufficient detail to give staff adequate information about the levels of support individuals needed. The care plans had been developed from the assessments made on individuals. This included risk assessments that were both generic and had individual elements that promoted independence and freedom where possible. The daily statements made by staff were of good quality and stated what support had been given to enable the residents to maintain as much independence as was possible. The statements also demonstrated how individual choices had been respected throughout their day. Staff were observed to interact with residents in a respectful way encouraging them to participate in tasks around their own home. This includes cleaning their room and participating in meal preparation. The Expert by Experience reported “Everyone cleans their rooms on Mondays Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 10 and are allowed to keep what ever they want in their rooms. They all do their own washing on Tuesday and Fridays, and they choose what they want to wear.” Information about residents is handled in confidence and in a sensitive manner. Staff spoke with residents and encouraged them to speak for themselves in stating how much of their individual stories they wished to share with the inspector. The Expert by Experience reported “The staff encourage daily meetings for everyone living at the home to choose food and activities.” Staff spoken to demonstrated a good knowledge of assessments and care support around behaviour that may be challenging. The Expert by Experience reported “The staff all interacted well with the people living at the home.” Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Residents, and their representatives can be confident that the home enables residents to maintain appropriate lifestyle with individual opportunities and support. Decisions around personal and family relationships are respected. EVIDENCE: Evidence from care plans, daily statements and from talking to staff and residents confirmed that the opportunities to socialise and participate within the local community were regular and quite individual. Activities based both in the community, at the home; including education and access to day services and college courses were evident on an individual basis. The home has two vehicles that staff and residents use. The Expert by Experience reported “On Thursdays a teacher comes to the home to help with reading and writing. The house has lovely gardens and an allotment area where everyone helps grow vegetables. One person goes to Sudbury day centre where they sorts, paper, bottles and plastics, they are picked up by bus. Everyone has the choice to go swimming on Fridays”. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 12 Care plans and staff demonstrated that residents were able to see family and friends of their own choosing, in private if desired. One relative who responded to a questionnaire stated that they are welcomed at the home, they can visit in private and that they are kept informed of important matters affecting their relative. The home has a knock and wait policy instructing staff to respect the privacy of residents at all times. This was observed on the day. With regard to relationships the Expert by Experience said, “Everyone spoke well with each other all the time we were at the home”. The menus that have been created are with the involvement of the residents as is the shopping that is done from local stores. Residents were seen to be participating in shopping on the day and making choices around food that they liked. The meal that night was chilli con carne. The menu was available for all to see and changed in winter and summer. Each season had a five-week plan that rotated. The meals were traditional type home cooking with a roast on a Sunday using vegetables from the garden. There was also a selection of curries and pasta dishes as one resident had Italian connections. The dining room was separate and was being refurbished at the time of inspection. The Expert by Experience reported from three residents the following: “The food was good and they always had lots to eat. One person likes going shopping with the staff to choose food items. Their favourite meal is Chinese, which is brought in; they would eat this every day”. “The food was good and always a choice, they like quiche, they have three meals a day and make their own tea, no alcohol allowed but they can smoke outside”. “One person likes the food at the home especially fish and chips, if they do not like what has been made the staff will make them something else or they can make their own sandwich”. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. Residents, and their representatives can be confident that the home offers appropriate personal and health care support. Trained staff appropriately administers medication, but current practice could be further developed. EVIDENCE: Care plans set out the support the residents required in relation to their personal care and their physical needs. The daily statements made by staff stated what personal care and support was given to individuals. One resident spoken to was quite happy with the support offered and had a good understanding of why things happened in the way they did. All eight questionnaires were positive about the support offered and residents felt staff listened to them. Care plans recorded all health care and professional visits made. Entries were seen for the GP, chiropody, dentist, dietician and opticians. Staff were aware of specialist referrals through the clinical psychologists and regular reviews were attended and information form these was recorded. Medication was on the whole well managed with the home. All staff were adequately trained. Security of medication should be further enhanced as the current storage does no meet with Guidance for the Misuse of Drugs (Safe Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 14 Custody) Regulations 1973, Schedule 2. This could be achieved by replacing the current filing cabinet with a specialist drug cabinet attached to the wall or the floor. The person in charge of each shift did hold the drug key. The home has a monitored dosage system in place provided by a local chemist. Medication administration records were seen to have been consistently completed, with the initials of the person administering the medicine recorded on each occasion. Medication for one resident was audited. This was not able to tally exactly as there had been some medication carried forward from previous months that was not recorded. The manager agreed to address this matter for routine auditing to take place. PRN (as and when required) medication should have a written procedure for staff to follow as to when and how much medication they should administer or as the manager suggested this medication was no longer required, it should returned to the chemist. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Residents, and their representatives can be confident that the home has appropriate procedures in place to deal with complaints, protect residents from abuse and neglect. EVIDENCE: Neither the Commission or the home has received any complaints in the last year. The home has a complaints procedure in place. This forms part of the Service Users Guide. Residents surveyed stated that they knew who to speak to if they were unhappy and knew how to make a complaint. The one relative comment card said “we feel comfortable enough to make a complaint directly if the need ever arose”. In relation to protection of residents both the manager and staff have received appropriate training. The manager has specialist experience from his previous employment in this area. In the office was a copy of the joint local procedure agreed with Suffolk Social Services and Police. Staff recruitment files showed that the home take up an enhanced CRB (criminal records bureau) check on staff and a POVA (protection of vulnerable adults) check before staff start work at the home. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is good. Residents, and their representatives can largely be confident that the home is comfortable, generally well maintained and meets the needs of the existing resident group. EVIDENCE: As stated in the description of this home the home was refurbished at the time of registration to conform to the then minimum standards. This is still the case and the home is well maintained and well decorated throughout. All communal areas of the home were visited, as were three bedrooms once the permission of each resident was given. All communal areas are comfortable and clean and have personal touches that make it homely. The dining room was being refurbished including flooring, walls and furniture. Each bedroom seen was truly a reflection of the person who resided there. Feedback from residents is that they are happy with their accommodation. The Expert by Experience fed back: “The main lounge was fabulous with a high roof and big open fire and seating area for the residents. All the bedrooms have there own bathrooms except two. Those rooms are next door to a bathroom. One resident showed us their room, which had a TV, DVD, Radio, Dartboard and large Aquarian with four goldfish. Staff let all the people at the Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 17 home have their privacy in their rooms at any time. Everyone at the home has his or her own keys. There is a handyman who puts all their pictures up. There was a paving slab broken in the garden on the step, which was loose and dangerous”. When this was brought to the manager attention he agreed to have this repaired. In addition the second radiator in a residents bedroom was broken and the room was cold. In the same room, room 8 there was a long gap in the carpet, showing concrete. This was where the room had been remodelled. The laundry is well equipped and able to be used by the residents. There was a vent pipe for the tumble drier that had to go over the worktop and have the window open for ventilation. The large grounds are well maintained by a gardener, but residents are particularly keen on gardening and have developed the green house to produce several vegetables. Currently there was a big display of pumpkins that had been grown by residents. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36 Quality in this outcome area is excellent. Residents, and their representatives can be confident that the home employs suitable numbers of staff that are well recruited and adequately trained to meet the needs of the residents. EVIDENCE: Several weeks of the staffing rosters for the home were examined. The staffing levels for the home are three staff on duty during the day and at night two awake persons on duty. In addition there is the registered manager and a person who comes in five days a week during office hours to run the day service with an additional teacher who comes to the home on Thursdays. The staff group is a group of long serving staff. Three of whom said that they are very happy working at the home. The home does not use any agency or relief staff and offers consistency of care from within the staff group. The home employs a total of 13 care staff. All staff have or are doing NVQ 2. One person is doing NVQ 3 and one person is doing NVQ 4. There was evidence that new staff completed the Skills for Care induction program through Suffolk Social Services. There was evidence of basic food hygiene training, appointed first aid training, fire training and unisafe training. There was evidence of regular formal supervision of staff. From the five completed surveys from staff all staff said that they received regular formal supervision and had a good training and development program at the home. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 19 Recruitment records for two staff were examined and this showed all the required checks were in place and that a through recruitment process was followed. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42 Quality in this outcome area is good. Residents, and their representatives can be confident that the home is appropriately managed but matters around health and safety could be further improved. EVIDENCE: The registered manager is suitably qualified. He has several years relevant experience in working with people who have a learning disability. He is friendly and approachable and observations of him with residents showed that he had a good understanding of individual residents and that they liked him. Staff spoken with spoke highly of the manager. The one relative comment card spoke of ‘the high standard of care’ at the home. In relation to self-monitoring the home has a system in place that has already been running for over a year. This is based upon questionnaires to residents. Completed ones were seen in care plans. However the manager is in the process of developing a system called Total Quality Management. He explained that this is based around monitoring and improving the National Minimum Standards as well as feedback from advocates and family. It was agreed that Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 21 this would be examined at the next inspection at the home. The expert by experience reported involvement of residents as: “staff encouraged daily meetings for everyone living at the home to choose food and activities”. Since the last visit to the home the local Environmental Health Officer had visited and left the home with requirements. Action on some of these points was still outstanding. The home has a fire risk assessment in place. COSHH (Control of substances hazardous to health) assessment was in place. There was no evidence of regular recording of hot water temperatures, though the hot water is restricted to around 43°c and was said to be regularly checked by the handyman. Evidence was seen for the servicing of fire extinguishers, but there was no evidence of the fire system being serviced. The manager agreed to action this. The manager had a copy of the Health and Safety Executive publication Health and Safety in Care Homes. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 22 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 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 4 29 X 30 3 STAFFING Standard No Score 31 4 32 4 33 X 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 5(1) 24(1) Requirement The registered person must include the views of service users in the service users’ guide. This requirement is repeated from the previous inspection. Storage of medication must conform to the Guidance for Misuse of Drugs (Safe Custody) Regulations 1973 Schedule 2. Timescale for action 30/11/06 2. YA20 13 (2) 30/11/06 3. YA20 13 (2) 30/11/06 The medication administration record must accurately reflect how much medication is in stock. The home must be maintained therefore the following must be addressed: • The radiator in room 8 must be fully working to maintain adequate warmth. • The carpet in room 8 must be replaced. • The loose slab near the smoking area is a trip hazard and must be repaired. The registered manager must DS0000066414.V314666.R01.S.doc 4. YA24 23 (2) (b) 30/11/06 5. YA42 13 (4)(a) 30/11/06 Page 24 Brett Vale Residential Homes Ltd Version 5.2 6. YA42 13 (4) (a) ensure so far as is reasonably practicable the health, safety and welfare of service users and staff therefore the requirements made in the Environmental Health report from June 2006 must be actioned. The registered manager must ensure so far as is reasonably practicable the health, safety and welfare of service users and staff therefore the fire alarm system must be serviced. 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA36 YA20 YA42 Good Practice Recommendations The staff supervision schedule should be maintained and up-to-date, so that all staff receives at least six sessions a year. A written procedure should be in place for administration of PRN medication or medication returned to the chemist as suggested by the manager. In order that the monitoring of hot water temperatures is evidenced these findings with the date should be recorded. Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Brett Vale Residential Homes Ltd DS0000066414.V314666.R01.S.doc Version 5.2 Page 26 - 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. 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