Inspection on 16/05/07 for Bricklehampton Hall Nursing Home

This inspection was carried out on 16th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Bricklehampton Hall Nursing Home 08/02/06

Bricklehampton Hall Nursing Home 20/09/05

Bricklehampton Hall Nursing Home 02/03/05

Bricklehampton Hall Nursing Home 30/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Bricklehampton Hall Nursing Home Bricklehampton Nr Pershore Worcestershire WR10 3HQ Lead Inspector Yvonne South Key Unannounced Inspection 10:30 16th May 2007 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 Bricklehampton Hall Nursing Home DS0000004098.V329391.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. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bricklehampton Hall Nursing Home Address Bricklehampton Nr Pershore Worcestershire WR10 3HQ 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) 01386 710573 01386 710460 Classic Care Limited Mrs Carol Ann Harris Care Home 55 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (55), of places Physical disability (10), Physical disability over 65 years of age (55) Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th February 2006 Brief Description of the Service: Bricklehampton Hall is situated in a rural setting near Pershore and Evesham. The hall is a Regency building, which stands within seven acres of gardens and grounds, with views over the Bredon Hills. Over recent years the buildings and grounds have been considerably upgraded to a very high standard, in a style, which is in keeping with the period of the building. The home currently provides nursing care for fifty-five residents in spacious rooms with modern nursing equipment and facilities. The home provides a choice of ensuite, single and double rooms. Residents are able to have a telephone line in their bedrooms. Menus are varied and take into consideration individual choice. There is a call bell in all bedrooms, communal areas, toilets and bathrooms. Emergency call pendants are also available for residents who wish to walk out in the grounds unattended. Activities and social events are organised by the activities organiser. Visitors are welcome at any reasonable time. Three shaft lifts facilitate movement between floors and handrails are fitted where necessary to assist the less mobile. Classic Care Limited (Mrs Helen Kendall and Mr Tudor Jones) own the home and the registered manager is Mrs Carol Ann Harris. Mrs Kendall quoted the scale of fees on 29.05.07 to be between £495 and £725 per week. In the documentation submitted to the Commission for Social Care Inspection on 28.02.07 it was stated that, at that time, additional charges were made for; chiropody £12.60, hairdressing £4.80 to £26.25, Newspapers at cost including delivery charges, Telephone calls between 5p and 20p per unit, toiletries and sweets from the trolley shop between £1 and £4, and taxis at cost and 5 handling. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection since the previous inspection, which took place on 08.02.06, and the information obtained during fieldwork on 11.05.07. The fieldwork took place over eight and three quarter hours, during which the inspector spoke to five residents and four staff. Documents were assessed and a partial tour of the premises was also undertaken. Assistance was given by the registered manager and the registered providers. In February 2007 the home was asked by the CSCI to complete and return a pre-inspection questionnaire and to distribute questionnaires to the residents and health care professionals seeking their opinions of the service. To date responses have been received from eleven residents, ten relatives, two care managers and six health care professionals. The focus of this inspection was on the key National Minimum Standards. What the service does well: The service provides a comfortable, elegant environment for the people who live in the home. It is spacious, well maintained and furnished to a high standard. Good links are maintained with the community so that the home is seen to be part of village life. A wide range of activities and stimulation is provided so that people can choose to participate if they wished and yet do not become isolated if they choose to stay in their rooms. The standard of personal and social care is appreciated by the residents It has been said that; ‘excellent nursing staff are well led by the matron Carol Harris’ and ‘a good range of diversions and activities are offered’. A health care professional has stated that; Staff are always caring and act appropriately to individuals from all backgrounds and faiths’. ‘There is excellent continuity and good knowledge of residents’. ‘Good care planning, good identification and resolution of possible care issues’. ‘Good communication with GPs and specialists’. A varied, nutritional menu is provided and residents are supported in making their selection each day. Residents say that the food is ‘excellent’. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bricklehampton Hall Nursing Home DS0000004098.V329391.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 Bricklehampton Hall Nursing Home DS0000004098.V329391.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): 3 (The service does not provide intermediate care therefore standard 6 was not assessed.) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People are given the information and support they need to assist them in their decision regarding residence in the home. The service is only offered to people if their needs can be met in the home. EVIDENCE: The Statement of Purpose and Service Users’ Guide for the home were readily available and each resident had received a copy of the Service Users’ Guide. Ten of the questionnaires returned by residents indicated that they had received sufficient information to help them make a decision regarding residence in the home. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 9 During the field work the inspector case tracked the care of three residents. A very good record was seen of the initial inquiries and process, and before admission someone from the home had visited and assessed the needs of each person to ensure the service could provide the care needed before a place was offered. A health care professional stated in the questionnaire response that; ‘Comprehensive assessments are always carried out by the home prior to any admission’. Although acceptable, the assessment format used did not include all the topics listed in standard 3.3 of the National Minimum Standards. It was suggested that the document be developed to ensure all these care needs were considered. The questionnaires returned by the residents indicated that they considered that they had been well informed and supported before admission. Bricklehampton Hall Nursing Home DS0000004098.V329391.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. This judgement has been made using available evidence including a visit to this service. Staff have the information and support that they required to ensure residents receive the personal and health care they need with due respect for their privacy and dignity. EVIDENCE: The records that were seen indicated that care needs had been well assessed and detailed and informative plans were available to inform and guide staff in their duties. These plans had been regularly reviewed to ensure the information was kept up to date and the daily records indicated that residents had received the care they needed. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 11 Some minor weaknesses were identified. Some documents were not clearly dated, there was little evidence of the resident’s, or with their consent their relative’s, involvement in the care planning processes, care plans were needed for some wounds and one care plan needed to be updated. Two residents said that health care provision was good however the questionnaire responses indicated that some people found that the response to call bells had been slow. None the less care, support and staff were generally available when needed. The manager said that the issue regarding the call bells had also been identified through the home’s quality assurance surveys and in response changes had been made to work routines and deployment of staff. This had improved matters considerably. The questionnaires from health care professionals indicated that an almost daily visiting doctor service was provided to the home and patient’s clinical health care needs were met almost immediately when requested. One response stated that there were; ‘Repeated examples of very sick patients from hospital quickly improving with good care.’ Although there was little information in the records regarding the residents’ wishes in relation to ‘end of life care’ the questionnaire responses indicated that a good quality service was provided. The manager said that the home was about to be involved in a Worcestershire palliative care project, which would further strengthen this aspect of care. Communication between the home and relatives was considered by most people to be good, although two questionnaire responses identified concerns. It was observed that medication was well managed. Facilities were available for safe storage, assessment and planning if residents wished to manage independently. At the time of this inspection none of the residents did so. Medication storage, documentation and staff training were acceptable. It was suggested for additional safety that all hand written medication records, additions and amendments should be made and signed by two trained staff to ensure accuracy. It was observed that the staff treated residents respectfully. They were dressed smartly and appropriately according to their wishes. Staff knocked on doors before entering, phone calls could be made and received in private and mail was delivered to the addressee unopened. It was identified in a questionnaire that it was difficult to use large equipment in one bedroom and this had compromised privacy to some extent. The manager said that action had been taken as quickly as possible to resolve the situation. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A wide range of activities and stimulation is made available so that residents are able to make choices and participate if they wish. Links are maintained with the community, family, friends and faiths to the extent each person wishes. Privacy and dignity is respected and safeguarded. A wide choice of nutritional meals is offered each day so that residents are able to select the dishes that appeal to them. EVIDENCE: The pre-inspection questionnaire indicated that the home employed a full time Diversional Therapist and two Patient Service Managers. It was observed that very good individual records were maintained for all residents that indicated whether they had chosen to be involved in individual and or group events. Those who chose to remain in their rooms were visited regularly and enjoyed one to one support according to their wishes. Two residents in their rooms confirmed this. One person said that staff always ‘call in when passing’. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 13 The pre-inspection questionnaire listed a wide range of in-house and community events that were arranged for residents. For example; physical exercises to music, quizzes, bingo, poetry readings, reminiscence, board games, painting, garden parties, the church fete, and visits from Brownies and school children. Professional entertainers visited the home, and celebrations and special days were acknowledged. One resident attended college twice a week. The questionnaire responses from residents said that there were always, or usually, activities that they could take part in although one relative stated in the questionnaire that ‘Some people lacked stimulation.’ And another suggested that, ‘Some people might benefit from going out to day centres as more external stimulation would be of real benefit.’ Residents belonged to a range of different Christian religions and were able to participate in services in the home or the community as they wished. The sample of menus seen demonstrated that a choice of well-balanced meals was offered and it was seen that information was available in the kitchen regarding individual likes, dislikes and needs. A four week menu was in use and there was also an ‘alternative menu’ for those who preferred. Residents said that they liked the food and described it as ‘excellent’. One questionnaire response gave the opinion that there was not usually a wide choice for vegetarians. However the manager said that they had been made aware of this and it had now been addressed. Choices were identified for meals and staff spent time with the residents discussing the menu and selections. Residents were moving independently about the home and others were being moved about the home by staff that were kind and efficient. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have the information and support they need which enables them to raise their concerns with confidence that they will be listened to and their concerns will be addressed. Staff are well recruited and trained so that the people who live in the home are protected from abuse. EVIDENCE: Copies of the Statement of Purpose were readily available and the manager confirmed that all residents received a copy of the Service Users’ Guide when they moved into the home. These documents contained copies of the complaint procedure for the home. Of the eleven residents who completed and returned questionnaires to the Commission for Social Care Inspection six people said that they knew how to make a complaint. Three people said that they knew who to speak to if they were not happy and three people said that they usually did. When the inspector asked a resident if he had any concerns or complaints he replied; ‘You’re joking.’ The Commission for Social Care Inspection had received no complaints regarding the service since the last inspection. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 15 The pre-inspection questionnaire indicated that the home had received sixteen complaints in the twelve months between January 2006 and December 2006. They had all been investigated and responded to. In the home the records of eight complaints were assessed. These had concerned the speed the call bells were answered, one person’s attitude, missing property, lack of communication, and dietary problems. The records had been well maintained and indicated that these had all been investigated and responded to appropriately. A questionnaire respondent stated that: ‘I have had no complaints from patients or family that have not been immediately addressed’. The staff who spoke to the inspector confirmed that prior to their appointment, they had completed application forms, undertaken an interview, references had been taken up and checks by the Criminal Records Bureau (CRB) and of the Protection of Vulnerable Adults (PoVA) list had been made. The registered persons said that they were aware of the current requirements in relation to these checks and if the CRB check and full PoVA check had not been received, the new member of staff was allocated a mentor and was not permitted to assist with any resident’s personal care until the results had been received and their position confirmed. It was suggested that a written record would provide evidence that the new appointee was aware of the limitations placed on her/him and identify the mentor who would provide support Staff were aware of the action they needed to take should they receive a complaint or if they had concerns regarding the behaviour of others in relation to vulnerable people. Staff confirmed that they had received training regarding the identification of abuse and what to do if they had concerns. The manager said that more such training had been planned. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well maintained, decorated, furnished and equipped so that the people who live there are able to do so in a comfortable environment that suits their wishes and needs. Due attention and training ensures that the risks of cross infection are managed and reduced as far as possible for the protection of the residents. EVIDENCE: A partial tour of the home was conducted that included four bedrooms. Everywhere was spacious, clean and tidy, well maintained, decorated and furnished. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 17 It was observed that residents had brought into the home personal items of furniture, pictures, photographs and ornaments to personalise their rooms. Care had been taken in one bedroom to identify the people in photographs so that staff were able to support the resident and converse about the people in the photos accurately. The communal rooms were elegant and well arranged. Residents were able to make free use of them or stay in their own rooms according to their wishes. Extensive grounds offered open spaces, courtyards and a sensory garden. The manager and residents confirmed that good use was made of the gardens and the annual village fete was held in the grounds each summer. One questionnaire response stated: Very suitable for people from a well off background. I have heard it described as more like a country house hotel than a home’. Residents said that the home was always fresh and clean and a health care professional stated in the questionnaire that; ‘I am happy that the staff are aware of infection control guidance and follow laid down procedures’. Notifications to the Commission for Social Care Inspection had been appropriately made and questionnaires confirmed that the correct action had been taken in response to an outbreak of infection. The laundry and sluice areas were clean and well managed. Personal protective equipment was readily available for staff to use, and staff and their records confirmed that they had received training in infection control. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although under pressure at times there are sufficient well recruited and trained staff on duty to provide the care and support the residents need. EVIDENCE: The pre-inspection questionnaire stated that eleven nurses and forty care staff were employed. In addition there were fourteen ancillary and catering staff. The manager said that recruitment was currently underway for a registered nurse to work nights and three part time care staff. Once these posts had been filled the need for agency staff would be reduced. The staff told the inspector that they were under pressure at times when the home was full and due to the size and layout of the building but when the staff vacancies were filled ‘It was ok’. Some of the questionnaire responses indicated that some relatives had concerns regarding the staffing levels. One person considered that the money that had been spent on the environment would have been better used employing more staff. Other comments made included; ‘Staff numbers do not allow trips to A&E to be accompanied’ and ‘The existing staff really look under pressure most of the time’. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 19 However the pre-inspection questionnaire indicated that the home provided in excess of the care staff hours required using the Residential Forum Staffing Calculation. The duty rotas indicated that staffing levels were maintained and agency staff were used when necessary. The registered provider said that relatives were contacted whenever residents needed to attend A&E. If they were unable to respond efforts were always made to ensure the resident was supported by the home. One resident stated in the questionnaire that; ‘Would like a bath more often but I do understand a lot of people do’. The registered provider has been made aware of this and has undertaken to ensure the resident’s wishes are met. The manager said that the current staff team covered a full age range and included people from the Philippines, Thailand and Zaire. There were no communication difficulties and no specific needs had been identified regarding cultures and faiths. Long holidays (absences) were agreed when staff wished to visit to their home country. There were five male care assistants on the staff team so that a same sex carer could be provided for residents who expressed a preference. The pre-inspection questionnaire stated that eleven care staff had National Vocational Qualifications (NVQ). This equated to 28 , which is well below the 50 required in the National Minimum Standards. However the manager said that this was due to previously trained staff leaving the home. Six staff were currently on courses and one person was on an assessors course. This would lift the percentage to just under the required level. The pre-inspection questionnaire, staff and their records indicated that there was an ongoing commitment to training. A questionnaire response from a health care professional stated; ‘Staff always appear to follow guidance and have received training to provide appropriate care’. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and sound systems are in place to ensure the residents receive the care and support they need and the risks regarding health and safety are well managed. The quality of the service is well monitored and audited so that areas are identified and improved for the benefit of the residents and others in the home. EVIDENCE: The home is well managed by a trained and experienced nurse who is approachable, efficient and knowledgeable. In October 2006 she success fully achieved the Registered Manager’s Award. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 21 Questionnaire responses included the following statements; ‘The head of nursing care is very good.’ ‘It is an excellently managed and run private home’. A member of staff commented that the management was ‘very good and the home ran smoothly with the minimum of hassle’. Some of the questionnaire responses expressed concerns regarding the size and inflexibility of the fees, and the costs of moving in. Quality Assurance policies were in place and based on the home’s questionnaire surveys a development plan had been drawn up to address issues that had been identified. For example, following concerns raised by residents an analysis of when call bells were used most frequently had been made and resulted in a change of routines and staff task allocations. To improve communication with relatives/friends meetings were being arranged to provide regular opportunities to speak and listen. One of the providers had accessed the Annual Quality Assurance Assessment (AQAA) document that had recently been brought into use by the Commission for Social Care Inspection. It was being considered how this could be used effectively to assist in the ongoing development of the service. No personal money was held for residents in the home and they were advised not to hold large sums or valuables themselves. Invoices were raised for any expenditure incurred to cover such items as hairdressing and chiropody. Records were well maintained. A full health and safety audit had recently been conducted and an action plan had been developed in response. It was seen that a new accident book had been made available to meet the changes in regulations. The auditors provided a rolling cycle of advice, action plans and reviews. The audit had covered a wide range and had included for example, risk assessments, sickness absences, moving and handling, and stress awareness. In response to the staff questionnaires there had been a review of furniture and equipment available and purchases had been made where needs had been identified. The pre-inspection questionnaire indicated that systems and equipment were appropriately maintained, checked and serviced. Staff and their records confirmed that they had received appropriate training in health and safety matters. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 22 The Fire Log demonstrated that a comprehensive risk assessment had been conducted in May 2006. Routine checks were regularly undertaken and staff were receiving training and participating in drills. Bricklehampton Hall Nursing Home DS0000004098.V329391.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 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 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 4 X 4 X 4 X X 4 Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 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 OP7 Regulation 15 Requirement Care plans must whenever possible be made, reviewed and updated with the resident concerned, or with their consent, their representative. Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations It is recommended that efforts continue to increase the number of care staff that have National Vocational Qualifications so that residents benefit from their knowledge and expertise. Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Bricklehampton Hall Nursing Home DS0000004098.V329391.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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