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Inspection on 06/02/07 for Briar Close House Care Home

Also see our care home review for Briar Close House Care Home for more information

This inspection was carried out on 6th February 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home benefits from a management team than sets clear goals and standards, and provides good training and support. There is a stable staff group who know the residents well and are aware of their needs and wishes. Staff spoken to were knowledgeable, enthusiastic and committed and said they worked well as a team. Residents care planning documentation was detailed, clear, up to date and regularly reviewed. Personal support plans are well presented and individualised to provide staff with information and guidance. Documentation reflects the staff and managers hard work to ensure that residents` independence is promoted and they are offered a choice in many aspects of their lives. The home`s emphasis on supporting residents as individuals was clear from discussion with residents, relatives, and staff. Although Briar Close is a large home, the arrangement into four wings helps promote a homely environment that does not feel institutional. The home is clean, well decorated and generally well maintained. There is a choice of attractive communal areas, and each wing has its own living/dining area and kitchen. Residents have personalised their bedrooms and arranged them to suit their needs. Residents spoken with expressed a high degree of satisfaction with the accommodation and with the levels of care provided, `I am very happy living here`, `the staff and care received are excellent`,`I treat it like my own home as I was told when I first came`. Several residents commented that the home was always kept very clean. Staff were observed treating residents with kindness and sensitivity. There is a well established `key worker` system. There are residents meetings where residents can ask questions and air their views. The home was described as `brilliant`; `I think this home is really beautiful`. Residents said the food was `very good` and that they enjoyed their meals. The residents said they were consulted about their preferences. The home follow Derbyshire County Council`s safe guarding adults and recruitment and selection procedures, and there is a corporate complaints procedure. There is a system of quality assurance that is being developed internally as well as the corporate system `Your Views Our Actions`.

What has improved since the last inspection?

Both internal and external decoration have taken place improving the environment for residents and meeting requirements made at the last inspection. The home have a plan for on going decoration and replacement of some armchairs in the communal areas of the home. Arrangements for the storage and administration of medication have been reviewed and are satisfactory.

What the care home could do better:

The handrails at the entrance to the home and at one of the exits are unsightly and not fit for purpose.

CARE HOMES FOR OLDER PEOPLE Briar Close House Care Home Briar Close Borrowash Derby DE72 3GB Lead Inspector Denise Bate Key Unannounced Inspection 6th February 2007 09:30 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 Briar Close House Care Home DS0000035731.V327740.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. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briar Close House Care Home Address Briar Close Borrowash Derby DE72 3GB 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) 01332 718310 01332 718311 linda.trigg@derbyshire.gov.uk www.derbyshire.gov.uk Derbyshire County Council Linda Joy Trigg Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Briar Close is a 40 bedded home for older people situated in the village of Borrowash, near the city of Derby. Three places are available for respite care and three places for day care each day. The property was purpose built and is owned by the local authority, Derbyshire County Council. Residents’ bedrooms are situated on the ground floor. The first floor is used for staff facilities only and is accessed by stairs. There are no en-suite facilities. All bedrooms are attractively decorated and personalised. Communal areas are bright and décor is of a good standard. The home is divided into four units for ten people, each having its own kitchenette, and dining and lounge area. In addition, there is a large lounge at the entrance to the building. There is a garden area with outdoor seating. Support services are in place with a choice of General practitioners, and visiting district nurses, chiropodist, dentist and optician. Community psychiatric nurse, occupational therapist, physiotherapist and dietician are accessed as required. Staff training takes place to inform and enable staff to care for service users appropriately. Transport is arranged for those service users wishing to go out and in-house entertainment is arranged. Fees are up to £364 per week for permanent service users, but a range of prices for short term care service users. Extra charges are made for hairdressing, chiropody, magazines, newspapers and contributions towards outings. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. During the inspection eight residents, three relatives, two visiting professionals, and three staff members were spoken with. The manager and two deputy managers were present during the inspection and provided assistance and information. Written information was provided by the manager in the form of a pre inspection questionnaire. Ten resident surveys completed prior to the inspection provided feedback on the service and their comments are reflected in this report. A number of records were examined, including care planning documentation, minutes of meetings, regulation 26 visit records, staff files and medication records. Three residents were case tracked. A tour of the building took place. What the service does well: The home benefits from a management team than sets clear goals and standards, and provides good training and support. There is a stable staff group who know the residents well and are aware of their needs and wishes. Staff spoken to were knowledgeable, enthusiastic and committed and said they worked well as a team. Residents care planning documentation was detailed, clear, up to date and regularly reviewed. Personal support plans are well presented and individualised to provide staff with information and guidance. Documentation reflects the staff and managers hard work to ensure that residents’ independence is promoted and they are offered a choice in many aspects of their lives. The home’s emphasis on supporting residents as individuals was clear from discussion with residents, relatives, and staff. Although Briar Close is a large home, the arrangement into four wings helps promote a homely environment that does not feel institutional. The home is clean, well decorated and generally well maintained. There is a choice of attractive communal areas, and each wing has its own living/dining area and kitchen. Residents have personalised their bedrooms and arranged them to suit their needs. Residents spoken with expressed a high degree of satisfaction with the accommodation and with the levels of care provided, ‘I am very happy living here’, ‘the staff and care received are excellent’,’I treat it like my own home as I was told when I first came’. Several residents commented that the home was always kept very clean. Staff were observed treating residents with kindness Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 6 and sensitivity. There is a well established ‘key worker’ system. There are residents meetings where residents can ask questions and air their views. The home was described as ‘brilliant’; ‘I think this home is really beautiful’. Residents said the food was ‘very good’ and that they enjoyed their meals. The residents said they were consulted about their preferences. The home follow Derbyshire County Council’s safe guarding adults and recruitment and selection procedures, and there is a corporate complaints procedure. There is a system of quality assurance that is being developed internally as well as the corporate system ‘Your Views Our Actions’. 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. Briar Close House Care Home DS0000035731.V327740.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 Briar Close House Care Home DS0000035731.V327740.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, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: A copy of the Statement of Purpose, Service User Guide, and other information is made available to current and potential residents. A copy of the most recent inspection report is kept on the notice board in the foyer together with other relevant information, e.g. complaints procedure. In practice quite a few residents become long term after attending the home for short term care or day care, so some prospective residents are sometimes already familiar with the service provided. Others decide to become residents through the home’s Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 9 local reputation or personal recommendation. Prospective residents or their advocates are encouraged to visit prior to making a decision. One relative was visiting the home on the day of inspection: comments on the surveys included ‘we paid a visit and checked it out’, ‘I just knew it was the right place for me’. Staff were heard encouraging relatives to phone in to get feedback on how recently placed residents were getting on. This provided reassurance to both residents and relatives that they were made welcome. A resident said to the inspector, ‘the staff were very kind and helped me to settle in’. Copies of assessments carried out by social services staff were seen on care planning documentation of case tracked residents. Two professionals from social services were visiting the home on the day of inspection. They said the home provided a good service, knew their residents well and provided a ‘warm, homely’ atmosphere. Communication was good and the home worked with other professionals to achieve individual goals, e.g. the home would assist residents to work towards increasing their independence if that was what people wanted. The home does not provide formal intermediate care and therefore standard 6 does not apply. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 10 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, 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are completed in detail and are highly individualised to demonstrate that residents’ health, personal and social care needs are being fully met. EVIDENCE: Derbyshire County Council have recently introduced a new system of care planning documentation and the home are in the process of transferring information onto ‘Framework I’. The three case tracked residents had clearly arranged care planning documentation covering all aspects of care. Items in files included the photo of the resident, front sheet with personal information, care plans, copies of reviews, personal service plans, risk assessments (moving and handling, falls prevention, nutrition), weight monitoring, health care professional visits, review forms and detailed day to day logs. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 11 Personal service plans were clearly written and resident focussed. All aspects of care were covered, including emotional and social needs, and indicated what personal routines were preferred. Personal service plans had been signed by residents, indicating that they had been discussed and agreed with them. The personal service plans are used as a working tool, well presented, written in clear language, and could be used in an emergency by people who are not familiar with their contents. The home have an efficient system of communication between staff shifts, which contributes towards consistency of care. All aspects of residents health needs and medication were clearly presented and records were up to date. The manager reported an excellent relationship with social services and health professionals. The local psycho geriatrician and Community Psychiatric Nurses provide support and advice when necessary. If residents’ needs change health and social service professionals give a ‘good response’ for requests for advice and/or reassessment. Residents and relatives spoken to spoke extremely highly of the excellent quality of care provided, ‘they can’t do enough for you’, ‘they have time to talk to you’, ‘the staff are very kind’, ‘I’ve only got to ask and whatever is possible is done’. A letter to the home described the staff as ‘friendly, patient, kind and very caring’. Staff were observed treating residents with dignity and respect. The circumstances of several residents had been very difficult, with one resident having recently suffered a bereavement. Staff were observed being supportive and reassuring. The home facilitate special friendships between residents, and several examples were given of this. Two residents had met at the home and got married. Their accommodation had been adapted to suit their preferences, and one of their rooms was a living room where they were served their meals. They told the inspector they were very happy and thought the home was ‘excellent’. There is a separate medication room with a medication trolley, lockable fridge and a controlled drug cabinet. The home uses the monitored dosage system, and there is a photo of each resident kept with the MARs sheets. The medication records of some case tracked residents were seen and found to have been recorded correctly. There are suitable arrangements for the recording and storage of controlled drugs, these were checked and found to be correct. There were sample signatures for staff dispensing medication, who had all received training. Fridge temperatures are recorded, as is the temperature of the medication room. The manager reported a good relationship with the supplying pharmacist who visits on a regular basis and is satisfied with the medication standards at the home and provides advice where Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 12 necessary. The home have access to medication reference books to provide information about particular drugs and their uses and side effects. On the day of inspection there were no residents who administered their own medication, but the home have a system of risk assessment which is used when this situation arises. One relative commented ‘staff always make sure the tablets are taken even though my mother has quite a complicated medication routine’. All staff administering medication have had training, but the home are also doing their own internal competency tests. There are corporate plans for all deputy managers to undergo further accredited training in medication issues. One of the deputy managers is contributing to the corporate group who are overseeing the introduction of new medication guidelines. There is a formal policy on death and dying, and the home and staff are committed to providing support to families and residents during difficult times. Several residents had died recently, and the manager explained what support had been provided. The home had received cards and letters from grateful relatives who had been helped in these circumstances. One current resident described the care and support that was given to her and her husband during his last illness, ‘I couldn’t fault them, they always came and talked to me and were very supportive’. Briar Close House Care Home DS0000035731.V327740.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 good. This judgement has been made using available evidence including a visit to this service. A varied programme of activities, outings and entertainment are provided that suit the expressed preferences of residents. This assists in contributing to a pleasant atmosphere and the overall high level of satisfaction for residents. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: One of the deputy managers is in charge of arranging activities. Residents are satisfied with the range and variety of activities offered. Regular activities include craft, quizzes, monthly outings, in house entertainment, bingo, shopping trips, chair based exercises, reminiscence, baking, theme evenings and religious services. Residents enjoy seasonal celebrations and birthdays, and outings. Erewash Museum plan to visit the home in the near future for a Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 14 special presentation based about reminiscence. There is a notice board on each wing giving information of events, menus, etc. The activities deputy manager has developed a number of feedback mechanisms, including recording residents’ of comments after activities or outings. Family and friends are also invited to special evenings and events. Along the corridors there were photographs taken of various outings which included trips to the seaside, meals out and riverside trips. Residents made the following comments to the inspector; ‘I really enjoy myself here’, ‘I love it here, you couldn’t get a better place’, ‘ we have a few laughs’. Other innovative initiatives being introduced by the activities deputy manager include recording residents’ memories and incidents from the past which may eventually be compiled into a book She has also carried out a quality assurance exercise compiled from information provided by District Nurses, doctors and social services staff. This system may provide useful information for self assessment and monitoring quality and could be formally compiled and feedback to residents. Most residents are local, and reflect the culture of the local community. Residents meetings are held on a regularly and there is an Erewash Forum of local authority homes in the area which has an independent ‘chair’ to which each care home sends two resident representatives. The minutes are circulated in the home and sent to senior members of staff in Derbyshire County Council. They were made available to the inspector. Issues raised included some issues of consistency between homes, e.g. standard of meals, as well as specific issues such as staffing and the availability of arrangements for ‘social drinking’. There were also matters on which further information was being sought. The Forum appears to be an innovative and interesting way of empowering residents to voice their views. The homes also have also started publishing a joint newsletter for residents, relatives and friends. Relatives spoken to indicated that they were made welcome to the home and were confident that the home would communicate any changes in their relative’s circumstances. Residents and relatives spoken to were extremely complimentary about the standard of catering, and the choice of menus available: ‘the food is excellent’, ‘I can ask for something different if I don’t like what is on the menu’. Briar Close House Care Home DS0000035731.V327740.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 good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure, although most relatives and residents prefer to raise issues on a more informal basis. The management team is viewed by residents and relatives as approachable and responsive. There have been some minor complaints recorded over the last year on a variety of issues which the home view as an important part of their quality monitoring. Residents all emphasised they ‘had nothing to complaint about’, but if they were worried about anything would talk to the manager or the staff. One resident commented ‘If I’d got a problem I would say so’. Derbyshire County Council has clear procedures for dealing with the safety of residents and safeguarding them from harm. Staff spoken to showed an awareness of safeguarding adults issues and would pass any concerns on to their line manager. Training in safeguarding adults has been provided for staff. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 16 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, 21, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is purpose built and provides residents with an attractive and comfortable place to live. EVIDENCE: Brian Close is a comfortable purpose built home that provides a good standard of accommodation. The home is organised into ‘wings’ with a lounge/dining area. A separate kitchenette and bathrooms and toilets are sited on each ‘wing’. During this inspection communal areas of the home were seen and four residents bedrooms seen. There is a regular programme of routine maintenance. Four lounges have been redecorated in the last year. The Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 17 kitchenette in each wing is being upgraded; on the day of inspection one had been completed and another was being refurbished. Residents and their families are able to use these facilities to prepare drinks and snacks. Three bathrooms were seen and it was noted that the home have two bathrooms with parker baths. The bathrooms are of a reasonable size and well maintained. The home is well furnished and provides comfort and choice. Individual bedrooms are personalised and many residents have their own furniture, televisions, music centres etc. Discussions with residents indicated that they were with the standard of accommodation. A resident commented, ‘I’m quite content and consider it my own home’. Another resident said she enjoyed having a ‘quiet time’ in her own room. The home was tidy on the day of inspection, and there was a high degree of satisfaction with cleanliness expressed through the questionnaires and on the day of inspection; ‘very good standards are kept’, ‘the home is very, very clean’. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 18 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. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: Information on staffing was provided which indicates that there are sufficient staff on duty to meet residents current needs. The manager has access to a ‘flexi-pot’ to finance extra staffing, and gave several examples of where this had been done for the benefit of residents. Staff spoken to were committed, enthusiastic, knowledgeable, and enjoyed their work. They felt they did an important job well; and this is certainly born out by the positive comments made to the inspector about standards within the home. They took part in both mandatory training and training on specific subjects to enhance their knowledge. Thorough induction had taken place for new staff. All staff, apart from one new person, have achieved NVQ level 2. Staff appreciated Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 19 the opportunities they had to undertake training and develop their skills. They said training made them more confident in themselves and in the roles they carried out within the home. Recent training completed had included fire safety, first aid, moving and handling up date, chair based exercises, continence care and bowel management. They said there was a stable staff group, they worked together well as a team and were a ‘close knit’ group who helped each other professionally and personally. The manager described her staff as ‘very hard working’. Staff meetings are held on a regular basis; these are ‘shift’ meetings e.g. morning, afternoon or night shift. Staff are encouraged to be open and honest about raising issues to contribute to the agenda. Three staff files were seen and all had relevant information including CRB checks, references but not copies of application forms, which are held centrally. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 20 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, 32, 33, 3, 36,38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and demonstrates good leadership skills. Staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: The manager is experienced and suitably qualified to run the home and has a sound knowledge of every aspect of care home management, including quality Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 21 assurance and a commitment to continuous improvement. Staff indicated that the manager was clear in the standards expected of them and effective leadership and guidance is given in respect of staff roles and responsibilities. Good administration systems are in place and there is evidence of regular updating of records. There is good communication throughout the home and between shifts, ensuring that resident care remains appropriate, consistent and resident focussed. There is a clear management and delegation structure with each of the three deputy managers being responsible for particular aspects of home management; i.e. care planning and risk assessments, outings and activities, housekeeping and domestic. As indicated previously, residents and relatives spoke positively about the management team, and felt confident that any matters raised with them would be dealt with. The inspector was informed that the home is visited regularly by a representative of the registered person and copies of Regulation 26 visits were available, indicating that day to day matters are looked into, and action take where appropriate. There are a variety of quality assurance approaches taken, e.g. questionnaires, residents meetings, Erewash Forum, that are referred to earlier in this report. The home keep copies of cards, letters from relatives, and letters of commendation; thus providing informal feedback on standards of care as well as the formal approaches previously outlined. Staff confirmed that they have regular supervision and that they find the management team supportive in their approach. Some supervision happens individually and group supervision is also in place. Staff indicated that they feel valued and supported. The inspector was informed that at present residents’ personal finance records are kept through Derbyshire County Council’s manual scheme which appears to work satisfactorily. Information on maintenance and health and safety records was provided by the manager in the pre-inspection questionnaire and indicates that matters relating to health and safety are satisfactory. Briar Close House Care Home DS0000035731.V327740.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 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 3 X 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X 3 3 X 3 Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)(b) Requirement The external handrails must be replaced. Timescale for action 15/04/07 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 OP29 Good Practice Recommendations Copies of staff employment application forms should be kept at the home. Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Briar Close House Care Home DS0000035731.V327740.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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