Inspection on 25/06/07 for Briars Residential Home

This inspection was carried out on 25th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Briars Residential Home 25/01/06

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 June 2007 11:00 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.V345843.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. Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briars Residential Home Address 23 Hunts Hill Glemsford Sudbury Suffolk CO10 7RP 01787 881185 01787 881104 thebriarsresidential@co.uk 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 Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (17) of places Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th January 2006 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 original building but benefit from modern design. An additional seven bedrooms, a first floor lounge, toilets, bathrooms and an extension 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. At the time of writing the agency charged between £400.00 and £500.00 per week, extra charges for some activities and outings. Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection of The Briars Residential Home and took place on 25th June 2007. It was a “Key” inspection, which focused on the key standards relating to Care Homes for Older People. Standards not inspected have been met at the previous inspections and there was no information that suggested this situation had changed. The report has been written using accumulated evidence gathered prior to and during the inspection. The Registered Manager, Irene Worsdell was on annual leave. We were able to feedback and discuss the inspection with them over the telephone on their return. Both senior carers were available at the home and were positive about the inspection, and were happy to discuss the service provided. Surveys were returned from eight residents, eight relative/visitors, seven staff and three health care professionals. We were able to speak with residents freely about their experience of living at the home. Comments from completed surveys and discussion with residents, staff and other interested parties, have been incorporated into this report. What the service does well: What has improved since the last inspection? Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 6 The home has continued to develop its service in order to accommodate people with different needs. Appropriate training has been completed and discussion with the staff team showed that they were always looking for areas where they could improve the experience for residents’. A medication trolley had been purchased and a Monitored Dosage System had been introduced. Generally staff felt that this had made medication administration much easier, safer and quicker. The home has moved its laundry to a larger area, which benefited staff and improved some aspects of health and safety. There had been some increase in overall staffing levels to accommodate the increase in residents following the completion of the extension to the home. 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. Briars Residential Home DS0000024343.V345843.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 Briars Residential Home DS0000024343.V345843.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 (The Briars does not provide intermediate care , therefore 6 is not applicable). Quality in this outcome area is good. Residents can expect the home to appropriately assess their needs prior to moving in. They should therefore they be confident that their needs can be met and they will be safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In April 2006 the CSCI approved a variation to The Briar’s registration to include up to three residents with dementia. The Statement of Purpose and Service User Guide accurately reflected this change. Residents who are placed by the local authority have a community care assessment. Pre-assessment are also undertaken by visiting the person prior to offering them a place at the home. As previous inspections have recorded the pre assessment is used to inform an initial short-term care plan which is completed before admission. This is very detailed and includes information on Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 9 communication, diet and fluids, sight and hearing, continence, oral hygiene, monitoring safe environment, personal safety and risk, history of falls, mobility aids, mental state, social interests and hobbies, medication, allergies, personal hygiene and personal dressing. They are written as needs assessments with care instructions and evaluations. They also highlight long and short term needs. This is then transferred to the permanent care plan with any changes since admission recorded. The home is clear that due to the environment of the home it is only suitable for residents who are reasonably mobile, although they do try to meet changing needs. In addition they are clear that at present they only offer to accommodate people with the early stages of dementia (who are still reasonably independent) and whose behaviour does not pose a risk to them or others at the home. Briars Residential Home DS0000024343.V345843.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. Quality in this outcome area is good. People living at the home can expect that they will have a plan of care, which aims to meet their needs and reflect their choices. This should ensure that their care needs are met, risks identified, and they remain safe as far as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents care plans and records were looked at during the inspection. There had been no change to this system since the last inspection. They showed a link between the pre assessment, short-term care plan and the full plan. 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. Previous reports have been positive about this system of care planning. They include detailed information about individual’s background and personal history. This inspection highlighted that some plans needed further Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 11 development to reflect higher care needs and intended outcomes of more dependent residents. None of the three care plans assessed had individual outcomes for areas of need, including personal care. One care plan noted that a resident did not like to “take part in large group activities” but there was no information about how this could be approached or how else their social needs might be met. Staff demonstrated that they took appropriate action to ensure this person was “not left out” but this was not documented. Staff confirmed that they felt the needs of people living at The Briars had increased and that in some cases more information was needed in the care plans and assessment. Despite the lack of outcomes, care records clearly showed what residents had been doing by recording activities, baths etc. Whilst there were general risk assessments in place, a situation was discussed with the home with regards to residents leaving the home without their knowledge and the potential risk this might cause. In addition we discussed the home’s environment with regards to the need to ensure resident’s safety but allow them to move around freely. Senior staff confirmed that they complete care records during their shift time and did not currently have any supernumery time to review and/or amend care plans and risk assessments. Observation during the inspection showed that staff were respectful towards residents. They talked and joked together and there was a positive and warm atmosphere. Residents commented that they liked the staff, three residents talked with confirmed they could spend time alone in their bedrooms if they wanted. No concerns about privacy and dignity were raised. All eight residents who returned a survey said that they “Always or “Usually” received the care they needed. In addition all eight said that care staff “Always” listen and act on what they say. Five relatives who returned a survey said that the home gives the support/care to their relative that they expected or agreed. Three said this was “Usually” the case. Both the professional surveys that answered, felt that the home “Always” met the health care needs of individuals. Comments included: “ (they) ask advise to make individuals more comfortable” “willing to learn more” “very caring and considerate to individuals” Care plans showed that when necessary action requested by a GP or other health care professionals had been carried out. Since the last inspection the agency has introduced a new Monitored Dosage System for medication. Staff were pleased with the new system and said it was easier to manage. The lunchtime medication round was observed and we discussed the process with a staff member. Training had been provided for Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 12 those who administered to residents and the policy and procedure included their responsibilities and boundaries. Medication Administration Records (MAR) were in place with a photograph of each resident attached. Some gaps on the MAR were noted for three residents who had medicated cream. Three other gaps were noted for other medication. The home had purchased a suitable medication trolley that can be moved around the home and directly to residents who remained in their rooms. There were no controlled drugs at the home during this inspection. The cabinet was kept securely and a senior carer held the keys on each shift. Briars Residential Home DS0000024343.V345843.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. Overall residents can expect the home to address their social and recreational needs and provide a varied diet. The home recognises the need to continue to improve these areas especially for people who are less independent. This should go further to ensure that individual’s choices are safeguarded and respected and their needs in this area are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of residents and their families/representatives were positive about daily life at The Briars. All seven resident’s who answered, said there were “Always” or “Usually” activities they could join in with. At the inspection resident’s talked happily about how they had been involved with choosing and planting flower pots that were on display outside the home. Staff had accompanied them to a local shop where they chose the flowers they liked. Some staff had undertaken training around the provision of activities through Suffolk Art Link; one staff member was taking overall responsibility for group activities. Resident’s had been involved with armchair exercises, craft and listening to a carer read different books out loud. The home had organised outside professionals to come to the home and provide short courses from a Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 14 local college. These had previously been free but the college had recently needed to start charging residents directly. Some surveys commented that trips out had been cancelled and they felt that residents with sensory loss were not always considered. For example, ”We are satisfied with the care provided for our relative although we are aware that (resident) would like more organised activities and events”. Senior carers agreed that the needs of some residents meant they had to look at different ideas and ways of engaging them positively. They also commented that some resident’s changed their minds about organised outings (this was often influenced by the weather). The home planned to introduce trips for small groups of residents (at any one time), which it was felt would be more manageable for staff and enjoyable for those taking part. Minutes from resident meetings showed that they had discussed ideas for activities, outings and events. Each resident had a record of the activities they had been involved with in their care plan. As noted in the section Health and Personal Care the individual aims and outcomes were not fully documented. Despite this the carer responsible kept a diary of the activities they facilitated and noted how it had gone and what resident’s thought (although there was not always a list of which resident’s attended). One person living at the home commented that in the last week they had enjoyed armchair exercises, listened to a carer read a book about Diana Princess of Wales and had chosen and planted some flowers. No concerns were raised about maintaining contact with friend and relatives. One resident had continued to attend the over 60’s club they had been to before moving to the home. All eight relatives/representatives said that their relative was “Always” or “Usually” supported to live the life they choose. Residents spoken with during the visit said they were free to spend time alone in their rooms or in one of the communal areas of the home. One person was observed being assisted to go outside to sit in the courtyard area. The Registered Manager had submitted menus for the home prior to the inspection. They were varied and showed the different options residents could chose from. Comments about meals included: “very good in terms of quality and quantity and choice” “…enjoys the meals the cook prepares and appreciates the fact that they have a choice.” “High standard of care, good food and attention to individual dietary needs” “Provide well balanced, appetising and varied menu” Briars Residential Home DS0000024343.V345843.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. Resident’s and their families/representatives can feel confident that the home will address their concerns appropriately and that they should be safeguarded from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All those who returned a survey (residents, relatives, staff and health professionals) said they knew how to make a complaint about the home. Of those that said they had complained all stated that the home had “Always” or Usually” dealt with it satisfactorily. One person commented, “Even minor concerns are dealt with quickly and taken seriously”. The CSCI was aware of one concern discussed with them but taken up directly with the home. The person involved stated that things were going well and the situation had been resolved. There had been no change in the home’s protection policy since the last inspection. The home had access to it’s own training team who provide a course on the Protection of Vulnerable Adults (POVA), which is also included on the home’s induction programme. The Registered 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.V345843.R01.S.doc Version 5.2 Page 16 Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is adequate. Overall residents benefit from comfortable surroundings and a pleasant atmosphere within the home. However shortfalls around fire safety and hot water temperatures does not always ensure the health and welfare of residents and has effected the quality outcome in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Briars is an old style cottage that has been extended at the back to provide more accommodation and a large dining room. The rooms are decorated and furnished in a cosy and homely way. Ten of the seventeen rooms have en suite facilities. The home has 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 is installed on the ground and first floor corridors. Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 18 An environmental tour was completed on the day of inspection. An outside cleaning firm had been brought in for a week, as the homes own domestic staff were not available. Although some shortfalls were noted it was accepted that the usual standard of cleaning had slipped because of this. Residents raised no concerns, with seven out of eight surveys stating that the home was “Always” fresh and clean. Water temperatures were tested in each area of the home and were within the recommended limit (around 43°). However, one en suite measured 55°. An immediate requirement was made to ensure this was addressed as soon as possible. Staff at the home contacted the maintenance team to fix it. A fire escape door was locked and some of the requirements from a fire service inspection (which had taken place in November 2006) had not been fully complied with. For example cupboard doors opening into corridors were not locked, and a fire door on the ground floor was not able to close properly as it was sticking on the carpet. Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 19 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. Overall resident’s benefit from staff that are well trained and have continued professional development. Managers recognise where further development is needed which should further to ensure that the needs of residents are recognised and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff files of two newly recruited employees were looked at. One had gaps in employment, which had not been explained by the applicant in the section provided. The other did not give any dates for education or date of birth so it was not possible to tell if they had provided their full working history as required by regulation. The home was advised that they must ask for full employment history of an employee in order to check their background and suitability for working with vulnerable adults. Both applicants had a Criminal Records Bureau Disclosure and had been checked against the Protection of Vulnerable Adults List prior to starting work. Of the six relatives/representatives who answered, five felt that the staff at The Briars had the right skills and experience to provide care. Comments from residents were generally positive about the staff team and during the inspection it was observed that there was a relaxed and happy atmosphere. All the staff who returned a survey said that they had training which was relevant to their role, helped them understand and meet the individual needs of Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 20 residents and kept them up to date with new ways of working. In addition they all felt that the Registered Manager gave them support and discussed how they were working with them. Some feedback indicated that training around managing people with behavioural or challenging behaviour would be useful. The home has it’s own in house training which also provides induction in line with the Common Induction Standards from Skills for Care. Further training included continence care, moving and handling, emergency first aid, palliative care, medication, health and safety, protection of vulnerable adults and dementia. Not all staff had received training around dementia care, however it had been booked to take place in the near future with a leading charity in the field. The Registered Manager said they would look at providing further training around sensory loss and activities for people with higher dependencies. Previous Inspections identified that staff at The Briars have been encouraged and supported to complete National Vocational Qualifications. The Registered Manger confirmed that seven staff had completed NVQ2 or above with a further three working towards the qualification. Following the completion of the extension and additional rooms, the home provided CSCI with a phased plan for increasing staffing levels in line with the planned increase in residents. The home had not reached full capacity at this inspection and so the increase in staff had not been fully introduced (although a new cook and domestic staff were in place). It was evident through staff surveys, discussion and observation on the day that the needs of some residents had increased and this had impacted on the amount of one to one time staff were able to spend with each person. Staff commented that sometimes more independent residents found it difficult to interact and understand the actions of more dependent people living at the home. One person commented, “Having residents who have very different personal needs in the same home can cause difficulty between residents”. Despite this feedback was generally positive. Comments included: “It tries to help people in different ways according to their individual needs”. “They make every effort to meet quite complex, emotional, physical and mental needs.” “Staff are always kind and friendly. I like (staff member) a lot we talk and laugh together, nothing is too much trouble.” Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37 & 38. Quality in this outcome area is good. Resident’s benefit from the consistently positive and proactive approach of the home. They can be confident that the home is run in their best interests and that their views will be listened to and always considered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has been in post since March 2004, but had worked at The Briars previously as a carer. They have completed the Registered Managers Award/NVQ4 and have continued to update their knowledge. Feedback from staff was very positive about their support and management of the service. Residents spoken with at the inspection knew who the manager was and said they felt able to speak with them about any concerns they might have. A professional comment card said that the home interacted with Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 22 individuals “across the board” and felt that the only improvement would be “Keeping on top of their good management skills.” Minutes of resident meetings were available at the home. In addition individual reviews take place with residents to find out what their experience of living in the home is like. As noted in previous sections of this report The Briars encourage residents to partake in decision-making. Previous inspections have noted that people living at the home were consulted about building work and given the opportunity to comment on staff, food, activities and the general running of the home. As noted in the section Complaints and Protection, residents and their relatives/representative were confident that the home takes any concerns seriously and works to ensure they were resolved satisfactorily. Whilst the home does not take any financial responsibility for resident’s money, they do receipt and record outgoings for residents who need help with buying papers, having the hairdresser etc. In these cases the home has an appropriate policy and procedure and records are kept. Previous sections in this report have highlighted where some record keeping needs to improve, for example some care planning and recruitment files. Overall information at the home is well organised and kept securely. However it was noted that the upstairs corridor had boxes of old files and care records that were stacked up. This could breach the homes confidentiality policy and may also have posed a risk in case of fire. As noted in the section of this report called Environment, the home needed to take action with regards to shortfalls around fire safety and hot water temperatures. The home took immediate action to start to address these shortfalls during the inspection. Staff complete some records and handover in the kitchen of the home. We expressed some concern about the appropriateness of this with regards to infection control, health and hygiene etc. The senior carer on duty stated that they planned to put a desk in a wide space in the corridor and conduct handover, and any confidential discussions, in the manager’s office. Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X 2 2 Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 OP37 Regulation 13(2) Requirement Medication Administration Records must be completed in full. The reason for any gaps must be documented along with any necessary follows up action, in order to safeguard residents from further errors. The home must know if a resident leaves the building and appropriate risk assessments must be in place for resident’s who wish to go out alone. This is to ensure that any risks are identified and that residents are safeguarded as far as possible. The home must ensure that new employees provide a full work history and any gaps must be explored and recorded. This is to safeguard residents from unsuitable staff. The home must ensure that all hot water accessible to residents is delivered at around 43°. This is to safeguard residents against the risk of scolds or burns. Fire escape doors must not be locked at any time. An alternative system must be DS0000024343.V345843.R01.S.doc Timescale for action 25/06/07 2. OP14 OP18 OP38 12, 13 15/08/07 3. OP37 OP29 19 Schedule2 15/08/07 4 OP19 OP25 OP38 12, 13(4) 25/06/07 5 OP19 OP38 12, 13(4) 23(4) 25/06/07 Briars Residential Home Version 5.2 Page 25 found so that staff and residents are able to evacuate the building safely. 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 OP7 Good Practice Recommendations Care plans should include the intended outcomes for needs identified. This should ensure that residents benefit from a consistent approach and that their health and welfare is safeguarded as far as possible. Development of activities for those with sensory loss and higher care needs would go further to ensure that all residents are stimulated and experience good outcomes in this area. 2. OP12 Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Briars Residential Home DS0000024343.V345843.R01.S.doc Version 5.2 Page 27 - 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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