Inspection on 25/01/06 for Briars Residential Home

This inspection was carried out on 25th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Briars Residential Home 25/06/07

Briars Residential Home 16/02/05

Briars Residential Home 17/11/04

Briars Residential Home 09/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Briars Residential Home 23 Hunts Hill Glemsford Sudbury Suffolk CO10 7RP Lead Inspector Jo Govett Unannounced Inspection 25th January 2006 11:30 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 Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Briars Residential Home Address 23 Hunts Hill Glemsford Sudbury Suffolk CO10 7RP 01787 282249 01787 282999 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) Ms Karen Julia Stokeld Mrs Irene Worsdell Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: The Briars Residential Home is situated in the small village of Glemsford close to Sudbury. It is next door to the local social club and within walking distance of a general store. The Briars is an older style property, which has a “cottage” feel to it and retains many of its original features from when the building was a domestic dwelling. Further adaptations have been made since the initial registration, which fit in with the age and style of the origional building but benefit from modern design. An additional seven bedrooms, a first floor lounge, toilets, bathrooms and an extention to the dining area were completed in November 2005 . The property has its own parking with a patio area to the rear, and a small front garden. It is able to offer accommodation and care for up to seventeen older people. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 25 January 2006 and was unannounced. Since the last inspection the home has completed building work to increase the number of bedrooms, bathrooms and communal areas. They can now provide care for up to seventeen elderly residents over 65 years of age. On the day of inspection eleven residents were living at The Briars and they had six vacancies. We spoke with staff, residents and the Registered Manager, Mrs Irene Worsdell. We saw a variety of documentation and looked around all areas of the home. We assessed the progress of previous requirements, and completed inspecting the Key Standards. It is therefore recommended that any reader of this report should also see the previous report completed on the 17 August 2005. Evidence and judgements for sections of this report called Health and Personal Care, Complaints and Protection and Staffing have been reproduced from the previous report. This has been agreed with the Registered Manager as the Scoring of Outcomes for these sections have not been published. What the service does well: What has improved since the last inspection? Residents and staff said they were glad that the building work had been completed, and also said that the results were “very good”. All those spoken with said that they were pleased with the larger dining room and thought the new bedrooms were “lovely”. The home now has personnel files available for inspection at the home, which includes all the elements, required by regulation. A new full time cook has been appointed and has started to develop new systems for the kitchen. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 6 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. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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 Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 (Standard 6 is not applicable). Residents and their representatives can continue to expect the home to provide accurate information about the services it offers. EVIDENCE: The home submitted an application to the CSCI to increase residents from ten to seventeen following the completion of an extension to the home. A new certificate of registration was issued in November 2005, following a site visit by an inspector and the receipt of certificates from other regulators e.g., fire, gas and electrical, environmental health. Previous visits and inspection reports evidenced that the home kept it’s existing residents well informed about progress and consulted with them at resident meetings and on a daily basis. The home’s Statement of Purpose and Service User Guide has been amended to reflect the changes and includes all the elements required by regulation. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. The home places the needs of residents very highly. Needs are identified and actions are in place for that should ensure they are met on a continual basis. This safeguards residents and staff from potential risk. EVIDENCE: The evidence for the assessment of these National Minimum Standards was collected during the previous inspection: “Two care plans were seen. These show a link between the pre assessment, short-term care plan and the full plan. The plans are user friendly and staff commented that they were easy to complete, review and find information. Sections included; Personal Information / Eating & Drinking / Observations / Breathing / Moving & Handling / Personal Care / Dressing / Eliminating / Work / Play / Personal History / Mental Status / Memory / Emotional / Family / Social Aims / Medical Information. Key workers are responsible for keeping files up to date and reviewed. Entries were detailed and proactive. For example they include different approaches to Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 10 try to get one resident to join in activities and meetings. Another gave specific details about the presentation of food. Previous inspections have consulted with the Commission for Social Care Inspection’s Pharmacist Inspector. The system in place using dossett boxes and separate bottles for “between” prescriptions, have been deemed acceptable. Staff confirmed that there is no “double dispensing”. The Manager said that with the potential increase in numbers from the additional bedrooms, they would be looking at possibilities for a new system, which would allow the safe transportation of medication around the home. Currently the medication and records are locked away in a kitchen cupboard. There are no controlled drugs. Eye drops were correctly labelled and dated. Records were completed in full, signed and dated. During the inspection staff attended an induction meeting for a distance-learning course on Medication Awareness. A previous inspection had evidenced that some senior members of staff had already completed a course on the safe handling of medication. The Manager confirmed that they were therefore the only members of staff to give medication. We were able to talk with 6 residents. They were positive about the continuing building work and the possibility that new residents would be moving in. They had been involved with the decision-making and said they thought they had been “listened too”. One resident said they were looking forward to “meeting new people and making new friends.” Minutes of meetings also confirmed that the extensions had been discussed at 5 meetings so far this year. Residents also commented that they liked the staff and “enjoy talking to them”. During the visit staff were seen accompanying residents to the toilet or their bedrooms. Interaction was friendly and familiar creating a relaxed atmosphere. Staff also knocked on doors before entering bedrooms and bathrooms and also allowed the inspector to chat with residents in the lounge alone without walking through or interrupting.” Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents can expect the home to provide suitable and stimulating activities. They also benefit from the home accessing different services and encouraging residents to partake in the decision making at the home. EVIDENCE: The home organises a variety of activities and social events. It does not employ a dedicated activities co-ordinator, this is seen as part of the carers daily duties. Currently some organised activity takes pace every day of the week apart from Mondays. Outside professionals visit the home to provide exercise, craft and reminiscence classes, specifically for the elderly, on a weekly basis. A hairdresser visits the home every Wednesday and the Registered Manager said that they incorporate a coffee morning into it to “make it feel like a social event”. At the weekends staff encourage residents to join in table games such as dominoes and cards, and on Sundays a vicar or priest attends the home. Residents and staff commented that the additional space in the dining area made it easier for people to do different things, but be together. Every two to three months residents are able to visit another home owned by the same Registered Provider, to have a day out including refreshments. This has also included watching a play by a theatre company the home hires. Last Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 12 year the home had accessed the local community bus to take residents on day trips including, Bury St Edmunds and Brent Ely. Residents spoke enthusiastically about their lives at the home. We talked with a group of four residents who said that they “really liked” the person who came to do the exercises, and spoke about the “weaved bags” they had made in their arts and crafts sessions. They also said that they had enjoyed Christmas especially the residents and relatives’ party, and the school children who came to sing at the home. Staff also commented that Christmas had been good and “very enjoyable”. The home has no specific budget for activities, but the Registered Manager said that the home’s owners always approved ideas. They actively seek professionals to provide activities and stimulation for residents. Care planning records this and the carers one to one and group activities. A residents meeting takes place at around six times a year. The Registered Manager stated that residents are all encouraged to attend to discuss and feedback on all areas of the home. Minutes are available that document discussion about food, activities, and the ongoing building work. The kitchen is of a family domestic style design with a large range cooker. Plans are in place to replace some of the equipment with more industrial appliances to accommodate the increase in residents. The home has had problems employing a cook in the past and the staff group (who undertook suitable training) took on the responsibility for cooking and preparing meals. The home has now successfully appointed a Cook who started the week of the inspection. A budget is in place and both the Cook and the Registered Manager confirmed that they would be working closely to monitor progress and develop ideas. New menus had been devised and put in place and the food is to be “cooked fresh every day”. A dietician had also visited the home to advise them on nutritional matters. The Cook shared plans to find out what residents like and dislike, and said they will then start to order food supplies accordingly. Residents are given the opportunity to comment on the food at resident meetings and their opinions are fed back to the kitchen staff. This is minuted and acted on, for example some residents had said that they did not like too much pastry. Staff also confirmed that residents make comments to them that they verbally feed back to the kitchen. The kitchen has a Hazard Analysis in place and is up to date and reviewed. Fridge, freezer and cooked meat temperatures are recorded and seen to fall within recommended limits. Checks for deliveries are also in place. The freezers are currently located outside of the kitchen in a hallway. The cook and Registered Manager have agreed alterations to the kitchen layout to accommodate them. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 13 Residents spoken with said that they could have different things if they asked, and had no concerns about the food. Relatives spoke about the Christmas party they had attended, commenting that the food had been “marvellous”. Residents said that they were able to choose where they ate meals. During the inspection some had tea in their bedrooms, while others sat in the lounge or dining room. Relatives visiting the home said that they were able to come in whenever they liked. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18. Residents can expect their concerns to be dealt with appropriately and for the home to act responsibly. EVIDENCE: The evidence for the assessment of these National Minimum Standards was collected during the previous inspection: “The home has a complaints procedure and policy. Two complaints had been received by the home since the last inspection. These had been acted on appropriately and actions and outcomes were recorded in a logbook. The procedure is also displayed on the notice board, service user guide and statement of purpose, and complies with the Care Homes Regulations 2001. Residents said that they were able to talk to staff “about anything that worries them” One person said that they felt “very comfortable” talking to a specific member of staff as they “never hurry me or tell me how I should do things”. The home has access to it’s own training team. A course on the Protection of Vulnerable Adults (POVA) is available and included on the home’s induction programme. The Manager had attended and completed a course on “Protecting Vulnerable Adults at Risk of Abuse” and had the certificate displayed. They were knowledgeable about procedures when a concern is raised. They had also attended meetings and forums with the local authority to keep up to date with new developments and strategies.” Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 15 Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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 the following standard(s): Residents can expect to live in a very attractive and well-maintained environment. EVIDENCE: This is the first inspection of The Briars since building work was completed and its registration changed to accommodate seventeen residents. Overall the building has been completed to a high standard and is well presented. The older parts of the home now lead seamlessly into the new. Ten of the seventeen rooms now have en suite facilities. The bedrooms have all the required furniture including an optional extra mirror. Each new bedroom is exactly 12 square metres or slightly above and each resident now has 5.4m of personal space in the communal areas. The home has also developed a policy about how the privacy and dignity of residents can be maintained when they use the toilet and shower facilities that open directly onto the dining/lounge areas. Lighting that is sensitive to movement has been installed on the ground and first floor extension corridors. The home now has over the minimum number of assisted bathrooms and toilets. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 17 We spoke with residents who had moved into new rooms. They said that they were very happy with the standard and like having their own en suite. Other residents said that they were glad the disruption caused by the building work had finished, but said that “it was a great improvement” and “ I really like the new furniture”. Rooms had been personalised by residents and they said they were free to put up pictures and photographs. One person said that carers had rearranged the furniture for them. Relatives visiting the home were very complementary about the new communal areas and bedrooms. Staff and residents said they were looking forward to sitting outside on the new patio during more clement weather. Despite some maintenance work being carried out, the home was clean and tidy during the inspection. Items that had been removed from an airing cupboard so carpentry work could be completed were replaced, so not to cause a hazard in the first floor lounge. We took further advice from another regulatory authority regarding resident’s use of a toilet that also had a sluice facility. We fed back to the home that although this was not ideal, as most residents have their own ensuite, risk of cross infection should be low, athough National Minimum Standard 21.9 states that: “Any sluices provided are located separately from service users’ wc and bathing facilities”. Although disposable paper hand towels were available in bathrooms, hand towels are also available to be used. We fed back to the manager that sharing towels could promote the spread of infection. The laundry door was open and cleaning materials stored there had not been locked away. Certificates and records of safety checks for fire equipment, fire alarms, emergency lighting, electrical wiring, lift, plumbing/heating and gas have all been submitted to the CSCI and are acceptable and highlight no concerns. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Resident’s benefit from staff who are trained and have continued professional development. EVIDENCE: As part of the new registration for seventeen residents, the home’s Registered Manager stated that recruitment and admission of new residents will be increased in parallel. The intended rota is available and shows the change for night staff, from one sleep in carer and one awake carer, to two waking night carers, and day staff to increase from two to three with added domestic hours. During the inspection the home was not full and had six vacancies. Although a the cook and domestic hours had been filled, new carers had not yet started as the residents had only increased by one. The previous inspection had required that all employee personnel files be available for inspection. At this visit files were available and included all the elements required for regulation including Criminal Bureau Record (CRB) Disclosures and Protection of Vulnerable Adult (POVA) List checks. Further evidence for the assessment of these National Minimum Standards was collected during the previous inspection: Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 19 “The home benefits from a personnel department that co-ordinates employment and induction training. A clear 20-point procedure is in place for the recruitment of new employees. This includes all the documentation required and CRB/POVA clearance policies. The previous inspection identified two staff files that were unavailable as they were at another site (personnel department). A requirement was made to ensure the home had the personnel files (or a certified copy) for all employees for inspection. At this inspection another file was unavailable and a second file had missing information including terms and conditions/contract, application form and health questionnaire/declaration. The manager confirmed that this information was still with the personnel department. A carer who had transferred from a domestic role to a carer position had not had a new Criminal Record Bureau (CRB) Disclosure completed. Although one had been received for their previous role, it had been completed before the POVA list came into force in July 2004. Therefore they had not been checked against the POVA register. The Manager shared that they were applying to be a counter signatory for CRB Disclosures and that this would lead to the home taking over recruitment procedures for themselves. They also stated that staff are not confirmed in position until an enhanced CRB Disclosure is received. New employees complete a 5-day induction programme before an offer of employment is made. Further to this the home follows a TOPSS 6 week induction programme and had been successful at exceeding the minimum ratio of 50 NVQ2 qualifications. Work place observation records were available alongside induction portfolios. As previously mentioned in this report staff were also completing distance learning courses on handling of medication and food hygiene. One resident said they “don’t understand why they (staff) have to do all that training” and they were “always doing something”. Other residents present said that they thought it was “good” and that they (carers) weren’t there “just for the money”. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 20 The home benefits from a personnel department that co-ordinates employment and induction training. A clear 20-point procedure is in place for the recruitment of new employees. This includes all the documentation required and CRB/POVA clearance policies. The previous inspection identified two staff files that were unavailable as they were at another site (personnel department). A requirement was made to ensure the home had the personnel files (or a certified copy) for all employees for inspection. At this inspection another file was unavailable and a second file had missing information including terms and conditions/contract, application form and health questionnaire/declaration. The manager confirmed that this information was still with the personnel department. A carer who had transferred from a domestic role to a carer position had not had a new Criminal Record Bureau (CRB) Disclosure completed. Although one had been received for their previous role, it had been completed before the POVA list came into force in July 2004. Therefore they had not been checked against the POVA register. The Manager shared that they were applying to be a counter signatory for CRB Disclosures and that this would lead to the home taking over recruitment procedures for themselves. They also stated that staff are not confirmed in position until an enhanced CRB Disclosure is received. New employees complete a 5-day induction programme before an offer of employment is made. Further to this the home follows a TOPSS 6 week induction programme and had been successful at exceeding the minimum ratio of 50 NVQ2 qualifications. Work place observation records were available alongside induction portfolios. As previously mentioned in this report staff were also completing distance learning courses on handling of medication and food hygiene. One resident said they “don’t understand why they (staff) have to do all that training” and they were “always doing something”. Other residents present said that they thought it was “good” and that they (carers) weren’t there “just for the money”.’ Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff and residents can expect clear leadership from the management of the home and the home to place high importance on the quality of its service. Continued and ongoing efforts to promote choice and independence benefit residents. EVIDENCE: Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 22 The home does not handle large amounts of residents’ own money. Most people at the home are able to take charge of their own finances or consult with family, friends or professionals. Small amounts of money for hairdressing, newspapers etc, are securely kept on request and a policy called “ Management of Service Users Finance and Property” is in place although we agreed with the Registered Manager that this needed updating, as it does not reflect current situation for example it refers to a Deputy Manager (which the home does not have) and not Seniors, and in practice two staff members (one must be a Senior) sign for any monies paid in or out. Records kept were seen to be correct when checked against the money held. As previous sections in this report have highlighted, the home tries to create an open and positive atmosphere for staff and residents. Minutes from staff and residents meetings show ongoing consultations. The Registered Manager stated that the Registered Providers and owners of the home support them with new ideas for the home. They also said that although the home is still relatively small, the increase in residents must not affect those already living there negatively. They have plans in place to increase to seventeen residents slowly, to ensure that that it is managed sensitively and the intimacy of the home is not lost. The home has health and safety policies and procedures and these are looked at on staff induction training, shadow shifts and staff meetings. Previous sections in this report show that the home needs to ensure that it has suitable kitchen equipment for the amount of residents at the home that hand towels are not shared in bathrooms, and COSHH materials need to be securely locked away. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 23 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 3 3 4 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38OP15 Regulation 13, 16 (2)(g) 13, 16(2)(j) 13, 23 (2)(l) 13 Requirement Timescale for action 30/04/06 2 3 4 OP38OP26 OP38 OP38 The home must evidence that equipment used in the kitchen is suitable and adequate for the amount it people it serves. The home must ensure that hand 20/02/06 towels are not shared in communal bathrooms. COSHH materials must be stored 20/02/06 securely in line with Health and Safety Regulations. The laundry door must be kept 20/02/06 locked when not in use. 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 Refer to Standard OP38OP15 OP38OP26 Good Practice Recommendations The home should ensure that eggs are “lion marked” and dated. The home should monitor the use of the toilet and sluice facilities on the first floor to ensure that risk of cross infection is minimised. Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 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 Briars Residential Home DS0000024343.V282101.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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