Inspection on 08/08/05 for Briarmede

This inspection was carried out on 8th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Briarmede 13/12/07

Briarmede 04/07/06

Briarmede 16/01/06

Briarmede 03/11/04

Briarmede 19/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Briarmede, 426/428 Rochdale Road, Middleton, Manchester, M24 2QW. Lead Inspector Diane Gaunt Unannounced 8 /9 August 2005 th th 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 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. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Briarmede Address 426/428 Rochdale Road, Middleton, Manchester, M24 2QW. 0161 653 2247 0161 653 2247 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr A Riley Care Home Only 30 Category(ies) of Old Age 30 registration, with number of places Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 30 service users to include:-up to 30 service users in the category of OP (Older People). 2. The service should employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection. Date of last inspection 3rd November 2004 Brief Description of the Service: Briarmede is an adapted building offering 24 hour care to 30 service users in 16 single and 7 double bedrooms. Bedrooms are located on both the ground and 1st floors. A passenger lift is provided. The home is situated on the main Middleton to Rochdale Road. It has been extended to provide a large lounge to the front of the building. Work currently in progress will provide additional single bedrooms and reduce the number of doubles. A new laundry, treatment/meeting room and office will also be provided. Access to the home is via one step into the front door. Public transport passes on a regular basis and the home is also in easy reach of the motorway network. A car park is provided to the rear of the home. It offers parking for approximately 12 cars and is accessed by one of two entrances. A lawned front garden is provided. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days. On the first day the pharmacy inspector visited to inspect medication. On the second day the inspector spent 10 hours at the home and spoke with six residents, three relatives, two senior care assistants, two care assistants, the deputy, the registered provider, the training officer, the cook, the hairdresser and a District Nurse. Care practice was observed and records looked at. Comment cards asking residents and relatives what they thought about the care at Briarmede had been given out a few weeks before the inspection. Six residents and 2 relatives filled the cards in and returned them to the Commission for Social Care Inspection (CSCI). Contact was made with two care managers. Their opinions are also included in the report. Requirements listed at the end of the report include 3 which had not been met from earlier inspections. There was no registered manager in post; the registered owner was managing the home with the support of the deputy. The owner intended to advertise for a manager. What the service does well: The home had care plans which were kept up to date and provided the information staff needed to care for residents. Residents and their relatives were asked what they thought about the care they were given. Staff were good at talking to residents to find out what they wanted, to offer comfort and support and to keep them company. Residents liked this and said staff were ‘very good at their job’, ‘nice and friendly’ and ‘helpful’. Healthy food was provided and was enjoyed by most of the residents. Staff were good at supporting and encouraging residents to eat. They did this in a kind, pleasant way. The home was good at looking into people’s complaints and changing things to make them better for residents. Training for staff to make sure they could do their job safely was regularly provided. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The home must make sure they do not provide care for residents they are not registered to care for and give them a written contract about their stay when they move in. The owner must make sure the bath without the hoist is available to residents who want to use it, and provide a private room for visitors to see residents in. A curtain to give residents privacy in room 19 must be provided. Another hoist to help move residents must be provided if healthcare professionals say it is needed. Shelves over radiators should be repainted or replaced. Staff must make sure that what they write down about residents taking their tablets and medicine is right and must only give the tablets from the packet the chemist sends them in. They should also add to the policies and procedures about medicines and measure small doses more accurately. More staff must be provided. Photographs of residents and details of social workers must be kept. CSCI must be told about any important that happens to residents. Staff must all go to a fire lecture and have a fire drill every year. Training about how to make sure residents are safe living at the home should be given to those that hadn’t had it. Staff must wear suitable shoes at work so that when they are helping residents they can do it safely. Senior staff should make sure residents weights are checked and make sure they do something about those losing weight. They should talk to residents and relatives about risks they take and get their agreement to how they are going to handle it. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 7 Activities should be checked to make sure they are what residents want and that they happen often enough. Meetings should be held with residents and relatives. 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. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 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 standard(s) 3. As intermediate care is not provided at Briarmede, standard 6 is not applicable. The assessment procedure in place did not ensure that the home was able to meet the needs of all residents admitted. EVIDENCE: Individual records were kept for each resident. All residents had a full care management assessment. In addition, the deputy or 3rd officer went out to assess potential residents in hospital or their own homes. These visits were documented and held on file but the home did not confirm the assessment in writing to potential residents informing them that it was able to meet their needs. In some instances residents had been inappropriately admitted, in particular this occurred when residents had a diagnosis of dementia. The home is not registered to provide care for people with dementia. Whilst there was evidence on file that the deputy had taken action for some residents to be reassessed by care managers and/or health professionals the residents remained at the home. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Residents and their relatives were consulted about required care, and involved in reviews to discuss changing care needs. Professionals were appropriately consulted regarding re-assessment and meeting of some residents needs, but action was not always taken swiftly enough to ensure health and care needs were appropriately met. Procedures were in place to facilitate the safe handling of medicines but some medication records were in need of improvement. Residents were treated with respect and their right to privacy largely upheld. EVIDENCE: Five individual plans of care were inspected and showed marked improvement since the last inspection. These care plans were in respect of four residents on permanent placement and one receiving respite care. They encompassed health and social care needs and recorded action to be taken to meet the needs. Where the home could not meet residents’ needs referral for reassessment had been made although appropriate action had not been taken to ensure these residents moved to a more suitable home. The care plans had been regularly reviewed by staff on a monthly basis and evidence of resident or relative involvement was seen on file. Relatives interviewed and those returning comment cards considered they were kept informed with regard to the residents’ care and well-being. Care plans clearly recorded GP, Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 11 Psychiatrist, District Nurse, CPN and care management involvement. Care managers considered care plans were followed and regularly reviewed. They said they were notified of significant events affecting their client’s well-being and considered staff demonstrated an understanding of residents’ needs, following and reviewing care plans. Residents, relatives and care managers returning comment cards all said they were satisfied with the overall care provided at the home. The District Nurse considered staff alerted the service appropriately with regard to pressure areas and skin tears. One resident had a pressure sore which she had on discharge from hospital, and which was healing. Turn charts were completed when required. Communication between the District Nursing service and the home was improving. Residents and relatives interviewed considered both health and care needs were met. Residents said the home called their GP when they needed them and the services of opticians, dentists, chiropodist and audiologist were accessed as and when necessary. Risk assessments were held on file but were not always agreed and signed by residents or relatives. Weights were recorded more regularly than previously but monitoring of weight loss was not always undertaken. In a number of instances however, food and fluid charts had been introduced for monitoring purposes. Staff encouraged residents to exercise by dancing, ball games and armchair exercises. One resident was supported to apply her own creams; the written assessment of safe self-administration did not clearly detail the support needed. Medication administration records were generally up-to-date, but there were some ‘blanks’ where entries had been omitted and on one occasion a lack of clarity where a ‘dosage change sheet’ had not been completed. The manager was aware of this issue and seeking improvement through monthly audit. The medication storage was generally orderly and secure. However, there were two unlabelled inhalers and one unlabelled bottle of medicine in stock. Residents returning comment cards and those interviewed considered their privacy and dignity was respected at the home. Care plans recorded individual wishes regarding receipt of personal care from male/female carers. Most of the staff interviewed were able to describe good practice in this area. Observation showed there was no privacy curtain in one occupied double room, the inspector was informed it had been broken for some time. This bedroom was also used by the District Nurse as a base during her visit. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 14 and 15 Social activities and occupation were provided but did not meet the needs of all the residents. Contact with family and friends was maintained but contact with the community had decreased reducing the social contact for some residents. Service users exerted choice on a day to day basis, providing them with some control over their lives. A nutritious, varied and balanced diet was provided and enjoyed by the majority of residents. EVIDENCE: Two of six residents returning comment cards considered suitable activities were provided, four considered this was only the case sometimes. Some of those interviewed said they thought the home should provide more in the way of activity but in the main had no specific suggestions to make. One resident said she would like the home to be more of a community with singsongs and church services. Staff said a karaoke machine was used; reminiscence sessions were held using music, videos and memorabilia; bingo, weekly arts and crafts sessions were held; carpet bowls and ball games were played and an entertainer visited every fortnight. Staff said a number of residents were occupied with household tasks which they enjoyed each day. Despite these activities a number of residents were seen to wander through the home throughout the day. There was no record of the activities undertaken by residents to enable the deputy to monitor their frequency or popularity. The Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 13 priest or eucharistic visitor called at the home to give communion to those who wanted it. There was no provision for those of other religious persuasion. All relatives interviewed and returning comment cards considered they were well received when visiting the home. They could see their relative in either communal areas or the privacy of their rooms. One visitor commented on the need for a private room, other than the bedroom, to see residents in private. An outstanding requirement is in place in this respect. Residents went out less with staff than they had done previously. Two residents had been out shopping with staff not long before the inspection but pub lunches and trips out to shows, local beauty spots arranged by the home had not happened for some time. Two residents were making arrangements to go on holiday – one with a friend and another with staff. Observation and discussion with residents and staff showed that residents were able to make day to day decisions regarding rising/retiring times, what clothing to wear, where to sit, what to eat, whether or not to be involved in activities. Service users wishes regarding involvement in their financial affairs were established on admission. One had chosen to control their own monies. The majority had asked relatives or friends to be responsible for finances. Advice regarding financial advocacy was held at the home if needed. Service users were able to bring personal possessions, including furniture with them, and evidence of this practice was seen in bedrooms. The Statement of Purpose stated that access to records was available in accordance with the Data Protection Act 1998, staff confirmed this. Menus inspected were seen to provide a varied diet over a 3 week period. Fresh fruit was served 2 or 3 times each week and residents said it was also offered as a snack and served as an alternative dessert most days. Two hot choices of lunchtime meals and a salad were offered each day and a hot and cold choice offered at teatime. Drinks were provided during the day and jugs of juice were available in the dining room which adjoined the lounge. Food served during the inspection was sampled, it looked, smelt and tasted appetising. Feedback from residents via interviews and comment cards was mostly positive with regard to food provision although two people said they enjoyed the food ‘sometimes’ rather than all the time. Those interviewed were unable to give suggestions for change but did say they could choose anything they wished if they did not like the menu’d meal. The cook was planned to include residents in reviewing menus. Diabetic and soft diets were provided for those who required them. Dietary and fluid charts were completed for those with reduced appetites or weight loss. Staff were observed giving appropriate assistance to those needing it and were both supportive and encouraging. Plate guards and adapted cutlery were available and in use by some residents. It was agreed this provision would be extended to another resident who was experiencing eating difficulties. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 and 18. Residents were confident that complaints would be listened to, taken seriously and acted upon. Satisfactory systems were in place to protect residents from abuse, a minority of staff were in need of training to ensure their full understanding of the procedures. EVIDENCE: The home had a complaints procedure. It was included in the Service User Guide, a copy of which was placed in each bedroom on a resident’s admission. It was also displayed on the ground floor corridor. A complaints book was in use and recorded complaints and action taken to address them. Four were recorded since the last inspection and appropriate action had been taken to address each one. The CSCI had received no complaints during this period. Residents and relatives interviewed and those returning comment knew to speak to the deputy if they wished to raise a matter of concern. A procedure for responding to allegations of abuse was available as was the Rochdale Inter-agency Protection of Vulnerable Adults (POVA) procedure. Appropriate reporting and recording procedures were in place. One internal POVA investigation had been undertaken in the home in conjunction with Rochdale SSD. It was appropriately managed and a suitable outcome achieved. In another instance care management had been appropriately informed. Staff spoken with understood the importance of reporting malpractice but were not all entirely clear about the different types of abuse. All senior staff and 4 carers had received POVA training provided by Rochdale SSD, one carer had watched an in-house video and 9 carers had received input through NVQ level 2 training. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 15 The Training Officer was planning to send all care staff on the Rochdale SSD course. Residents interviewed and those returning comment cards said they felt safe living at Briarmede. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 22. A safe environment was provided but, during ongoing building work, the home had not been well-maintained. Specialist equipment was provided but did not meet all residents’ needs. EVIDENCE: Internal building work had been ongoing at the home for some considerable time, although the 2nd stage to provide 3 single en suite bedrooms, an office and a meeting/hairdressing room was nearing completion. A plan detailing the timescale for the remaining work was submitted to CSCI with a completion date of June 2006. Some maintenance/renewal work had been undertaken during ongoing works but this was limited. The submitted plan included proposed dates for decoration and carpeting of corridors. Some maintenance work had been undertaken, broken light fittings had been mended and some bedrooms had been decorated and new carpets fitted. Requirements from the Greater Manchester Fire Service report of 19 August 2004 and the Environmental Health report of 02 March 2005 had been addressed. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 17 The home had a variety of aids in use: grab rails, handrails, adaptations to toilets, an assisted bath, a level access shower, moving belts and reachable call systems in all rooms. Sitting scales and a mobile standing hoist were also provided. Staff interviewed considered a number of residents would benefit form the provision of a different hoist. They described specific difficulties with one resident who could not weight bear on occasion. In these instances 3 carers were needed to move her. This resident was being reassessed. Large print books were available and those with sight impairment had been offered talking books. A passenger lift was provided. An outstanding recommendation was in place with regard to the provision of handrails to stairs. This was included in the maintenance and renewal plan. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28. Insufficient staff were provided to meet the needs of residents. EVIDENCE: Inspection of three weeks rotas showed that insufficient staff were provided to meet the minimum requirement. Feedback from staff, residents and relatives was mixed with regard to whether there were sufficient staff. Observation, discussion with staff and inspection of care plans highlighted the need for additional staff to provide the care needed by those residents who were in need of reassessment. Residents said staff were ‘very good at their job’, nice and friendly’, and ‘helpful’. Observation showed staff’s manner and approach to residents, especially those with dementia and depression was kind and caring. The deputy manager and 3rd officer had an NVQ level 2 as had 9 care staff. Two carers were taking NVQ level 2 and were due to finish in December 2005. A further five carers had registered for the course. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38. A suitable system was in place to ensure residents’ financial interests were safeguarded. With two exceptions, the health, welfare and safety of residents was promoted and protected. EVIDENCE: The home acted as appointee for one resident, this was a longstanding arrangement which the resident and their relative did not wish to change. One resident chose to manage his own monies and the remainder relied on relatives or friends to manage their financial affairs, some of whom held Power of Attorney. The majority of relatives chose to leave a sum of money in the safekeeping of the home for residents to access as and when they wished. All those spoken with were happy with this arrangement which was seen to work effectively on the day of inspection. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 20 Although required records (standard 37) was not fully inspected observation showed that a record of care manager’s telephone number and address were not always recorded and a photograph of the resident receiving respite care was not held on file. The CSCI had not been notified of a number of notifiable incidents. Maintenance and servicing of equipment and safety checks were undertaken within required timescales. A rolling programme of induction training in relation to health and safety issues was in place and inspection of training matrix and interviews with staff confirmed the majority of staff had completed it. All senior staff had completed 1st Aid training ensuring one per shift was trained. Although fire lecture had held regularly in the past, there had not been one within the last 12 months, neither had all staff had a fire drill during this period. A health and safety policy was in place and procedures posted on the notice board. Accidents were appropriately recorded and reported. The deputy was observed to be wearing open toed, backless sandals which were inappropriate and unsafe when assisting residents to move. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION 1 x x 2 x x x x STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x 3 x x 2 Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 23 Requirement A private room, other than residents bedrooms, must be provided for visitors to meet with residents. (Original timescale: on completion of extension) Terms and conditions/contracts must be issued to residents on admission and a copy held on file. (Original timescale: 31.05.2004) The unassisted bath must be made good and items stored in the room removed. (Original timescale: 31.12.2004) Full assessment must be undertaken prior to residents admission and action taken to ensure care is not provided to people outside of the registered categories of care. Medication administration records must be clear, complete, accurate and up-to-date. Medication must be administered from the original pharmacy labelled container A privacy curtain must be provided in room 19. Following assessment, suitable equipment must be provided to ensure the safe moving and Timescale for action 30.09.2005 2. 2 5 31.08.2005 3. 21 23 30.09.2005 4. 3 14 & Care Standards Act 2000 s.24 13 13 12 13 31.08.2005 5. 6. 7. 8. 9 9 10 22 12.09.2005 12.09.2005 31.08.2005 30.09.2005 Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 23 handling of all residents. 9. 10. 27 37 18 17 Sufficient staff must be provided to meet the needs of service users. Photographs of residents and contact numbers of social workers must be held on file and CSCI informed of any notifiable incidents within 24 hours of their occurrence. All staff must attend an annual fire lecture and have an annual fire drill. Staff must wear suitable footwear in order to safely meet the needs of residents. 31.08.2005 31.08.2005 11. 12. 38 38 23 13 31.10.2005 31.08.2005 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. 4. 5. 6. 7. 8. 9. 10. 11. 12. Refer to Standard 33 33 19 32 8 8 9 9 9 9 12 18 Good Practice Recommendations The annual development plan should be re-introduced. Policies and procedures should be reviewed regularly. Shelves over radiators should be made good. Regular staff and resident/relative meetings should be held. Residents weights should be monitored and action taken when weight loss is noted. Resident or relative agreement to risk assessments/strategies should be recorded. The medication policies and procedures should be reviewed and expanded; the advice of the supplying pharmacist should be sought. All handwritten MAR entries should be signed and where possible independently checked and countersigned. The medication receipt record should be signed. Oral syringes should be available for measuring small doses. Eye drops should be dated on first opening Activities should be recorded, monitored and reviewed to ensure all residents needs are met. All staff should have Protection of Vulnerable Adults F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 24 Briarmede, training. Briarmede, F06 F56 S25466 Briarmede V230494 09.08.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Turton Suite, Paragon Business Park, Chorley New Road, Horwich, Bolton, BL6 6HG. 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. 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