Inspection on 23/11/07 for Brightbow Lodge & Brightbow Court

This inspection was carried out on 23rd November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brightbow Lodge & Brightbow Court 04/01/07

Brightbow Lodge & Brightbow Court 15/08/06

Brightbow Lodge & Brightbow Court 16/12/05

Brightbow Lodge & Brightbow Court 29/06/05

Brightbow Lodge & Brightbow Court 10/03/05

Brightbow Lodge & Brightbow Court 30/06/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Brightbow Lodge & Brightbow Court 11-16 Philip Street Bedminster Bristol BS3 4EA Lead Inspector Savio Toson Key Unannounced Inspection 28th November 2007 09:00 Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 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 Brightbow Lodge & Brightbow Court DS0000020271.V352500.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 Adults 18-65. 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. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brightbow Lodge & Brightbow Court Address 11-16 Philip Street Bedminster Bristol BS3 4EA 0117 9636409 F/P 0117 9636409 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) The Lodge Rest Limited Vacancy. The home has employed a manager who has yet to be registered by us. Care Home 57 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (57), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (57) Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 57 persons aged 18 - 64 years with mental disorder requiring nursing care excluding persons detained under the Mental Health Act 1983 Manager must be a RN on parts 3 or 13 of the NMC Register Staffing notice dated 28/4/1994 applies May accommodate up to 57 people aged 65 years and over with mental disorder requiring nursing and/or personal care within the existing registered numbers, excluding persons detained under the Mental Health Act 1983 May accommodate up to 20 persons aged 18 - 64 years with mental disorder requiring personal care excluding persons detained under the Mental Health Act 1983 4th January 2007 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Brightbow Lodge and Court are located close to the city centre, within walking distance of local shops and amenities. Main bus routes and bus stops are nearby. The home has two separate premises on the same grounds but the two buildings have different managers and care staff. Brightbow Court has a manager but the ultimate managerial responsibility for the whole site is with the nurse manager based in Brightbow Lodge. The homes offer 24-hour social and nursing care, and are able to meet a range of needs. The people using services in these homes have a diverse range on needs. The diverse needs have been recognised by the service and individuals who were classified as continuing care are now being carefully relocated to services that provide continuing care. Current service users that do not need continuing care are engaging with staff within a “re-enablement strategy”. The description of a reenablement strategy and what it means for people using the service should appear in the statement of purpose. The home has an activities organiser who works with individuals to develop individualised, activity programmes. The emphasis is towards social, recreational, educational, or employment skills training. The cost per week to live in Brightbow Lodge or Court for new residents, is £600 and fees are reviewed annually. This weekly fee does not include the cost Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 5 for items such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can be provided with information about the home by using the Service Users Guide, which details the services and facilities offered by the home. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit to Brightbow Lodge and Court was over two days. The information collected for this inspection included evidence from a range of different sources, including: • Information provided by the manager in the pre-inspection questionnaire • Information taken from 19 resident survey forms (12 filled in with staff help) • Information from 2 professionals who visit the home • Speaking with 12 residents • Case tracking a number of residents • Speaking with care staff • Walking round the home • Looking at some of the homes records • Watching how the staff worked with residents. The overall analysis is that the home provides a complex service because of the wide range of needs of the people using the service. What the service does well: What has improved since the last inspection? What they could do better: Prospective residents visiting the home would need additional information to help them decide whether the home was right for them. The home needs to provide prospective residents with more information on how it considered the equality and diversity of its residents. Residents would receive more up to date care if their care needs were reviewed more regularly and potential risk assessments were included in the care plans. The service needs a more robust petty cash procedure, at least two of the corridor carpets need to be made safe or replaced and some of the older damaged furniture replaced. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 7 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. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 1,2,3, 5. Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents visiting the home would need additional information to help them decide whether the home was right for them. Residents move into the home with an understanding of the type of service and accommodation they can expect. EVIDENCE: Prospective residents visiting the home would need additional information to help them decide whether the home was right for them. Two documents, the statement of Purpose and Service User’s guide had some wrong information and were not easy to find. The Statement of Purpose contained nearly all the information required but arrangements for attending religious and spiritual services needed to be included, the complaints procedure needs to have the name of the previous manager removed and our new address included. The statement of purpose needs further information on how potential residents would have their diverse needs considered and supported by the service. Potential residents have their care needs assessed, by the service, before moving into the home. The care records viewed contained assessments from the organisations making the placement into Brightbow. The home sends out a pre assessment form to be filled out and the form has additional observations Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 10 made about the resident added, after they enter the home. One of the care records which was being case tracked did not contain an assessment which should have been filled in by the home. In the annual self assessment returned by the manager to us, he says, “we undertake comprehensive pre admission assessments for all referrals.. we explore with a focus on people’s capacity to achieve their stated goals.” Residents can move into the home knowing their needs will be met because the home applies an admission criteria to select who can enter to home. The manager was able to show information on a potential resident for whom the home decided they could not meet his needs. Residents move into the home with an understanding of the type of service and accommodation they can expect. Several accommodation agreements were viewed, they were kept in the care records. The agreement contained the fee to be paid, it was signed either the resident or their representative and a member of the home’s staff. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 6,7,9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive care from staff who use care plans which set out the individual needs of the residents. Residents may not be receiving up to date care from staff because not all care plans are regularly reviewed in a formal way by the staff but the manager said reviews do happen . Residents in Brightbow feel they can choose how to lead their lives. EVIDENCE: Residents receive care from staff who use care plans which set out the individual needs of the residents and describe how those needs can be met. However some of the care records viewed did not contain risk assessments. Which have information on the potential problems residents could experience during their stay in Brightbow. There was not enough information on the risks that residents could take or the effects on the resident if they took the risk and how the staff could deal with it. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 12 The manager had decided that daily statements on the resident’s well being only need to be recorded weekly or when a change has been observed. However the manager was advised of the ruling that if a care intervention by the staff had not been recorded it is assumed that the care had not been given. Also daily statements for a resident with changing needs were not being recorded. Residents may not be receiving up to date care from staff because not all the care records were regularly reviewed. Residents in Brightbow feel they can choose how to lead their lives. Several of the residents gave their views during the inspection about how they felt they could make choices about their food, their life style. “ I choose what I want to do as I’m quite independent”. Also “ I look after myself.” The Resident’s surveys contained comments such as “ I can come and go as I please. That’s why I like it here.” Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 12,13,14,15,16,17, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of nutritious and healthy meals. The residents in this home are offered a range of meaningful recreational activities. The residents receive medicines from staff who work in a home where medicine practices have been reviewed. EVIDENCE: Residents are offered a range of nutritious and healthy meals. The changes to the catering team has meant the menus have been changed and the meals on offer have more nutritional value. The deep fat fryer is no longer used and there would be no more “fry-ups”. More salads and healthy choices had been introduced. The changes were reflected in the menus viewed, they contained meals such as vegetable lasagne, tuna egg salad, sardines on toast. The residents were very aware that the meals had changed and several wanted a Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 14 return to their high fat, low fibre meals. Several residents said the food was “alright” one added “it is a little bit better”. Another said “the food isn’t better. They say it is. Well it’s better sometimes.” The decision to introduce this change in diet is acceptable because even though the new menus were healthier, they contained choice. And residents could still make individual requests to the chef if there was nothing on the new menu’s which they could eat. The home was also going for healthy eating awards. All this information put together made the current catering arrangements commendable. The residents in this home are offered a range of meaningful recreational activities. They activities varied so that a range of resident’s needs and abilities were being met. The activities timetable included residents having places at the local city farm. Helping out an animal sanctuary, learning computer skills as well as cinema sessions in the home. On the day of inspection several residents were preparing to go for their swimming sessions. Concern was expressed as to how the activities could be maintained when the activities organiser is away. For the continuity of service to change because the organiser was away, would be of concern. Residents live in a home where they can have visitors and entertain them according to the homes policy. Residents spoke of their friends and relatives visiting them. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home get the support from the staff to lead their own lifestyle. Residents are assisted in accessing healthcare facilities. EVIDENCE: Residents in the home get the support from the staff to lead their own lifestyle. The support the residents get from staff is given to suit the resident’s needs. Residents are allocated a named carer who gets to know the resident well enough to give consistent support. The named carer’s list was in the office and when asked, two residents knew they were allocated carer. Residents are assisted in accessing healthcare facilities. During the inspection a social worker visited a resident and carers were sorting out the arrangements for taking a resident to an out patients appointment. There was clear discussion between the resident and the carers to ensure the appointment would be kept. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 16 The residents receive medicines from staff who work in a home where medicine practices have been reviewed. The home is in regular contact with the pharmacist who provides the home with their medicines. The administration of medicines has changed and the staff now use a trolley to take the medicines to residents, the medicine administration sheets which were viewed were up to date. The medicines checked were within their use by date. When the controlled medicines were checked the amount recorded was the same as the medicines stored. However a potential error was found, one of the nurses had disposed of medicines without recording the transfer of the medicines into the disposal book. But a search recovered the missing medicines. The medicine disposal procedure had not been followed. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 22.23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know how to make a complaint or share concerns. Residents have staff looking after their interests and know how to follow the safeguarding of vulnerable adults procedure. EVIDENCE: Residents know how to make a complaint or share concerns. Out of the 19 surveys returned, eighteen residents said they knew how to make a complaint. The usual comments made were “I talk to the manager and put it writing”. The one resident who did not know how to make a complaint said they were happy over the seven years they lived in the home. The complaint’s procedure needed to be updated, it contained the previous manager’s name and the address of our recently closed CSCI office. The home also has a complaints register which when viewed showed there were no complaints received in the last six months. Residents have staff who now know how to follow the safeguarding of vulnerable adults procedure. A recent incident in the home showed that the staff did not follow the protection of vulnerable adults procedure. The Home recognised their errors and have now taken action to make sure staff are more aware of their responsibilities. Two staff were asked what action they would take if they thought abuse was taking place and both knew what they would have to do. Staff training on safeguarding adults wad also been arranged and was starting within the next few months. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 18 Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 24,25,26,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in an environment which is being maintained but some areas of the home need to be improved. Residents live in home where the domestic staff work hard at keeping the home clean and tidy. EVIDENCE: Residents live in an environment which is being kept in good repair, but some areas of the home need to be improved. Whilst walking around both homes, several of the residents were happy with their bedroom. The residents showed me how they decorated their bedrooms to their individual tastes. There were rooms which would benefit from redecorating but this was considered in the context of a major refurbishment of the home being planned for early next year. Therefore improvements to the environment were not going to form part of this report. However there were two maintenance issues which could not wait. The corridor carpet was curling up outside bedroom 32 of the lodge and the black, stained, wet corridor carpet around bedrooms 21 to 25 needed Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 20 urgent replacement. As already said in this report the lodge is going to be refurbished and converted into 3 separate units offering a services to residents with different needs. Some of the furniture fixtures and fittings were just adequate and would benefit from upgrading; for instance wardrobes, chest of drawers. Residents live in home where the domestic staff work hard at keeping the home clean and tidy. The domestic staff were seen working on both days of the inspection and socialising well with the residents. The areas which been covered by the cleaning schedule were clean and the domestic staff could explain the ways they had to adapt their work to meet the individual needs of the residents. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 31,32,33,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive a service from staff with a range of skills and abilities. Residents live in a home where the staff have been appropriately checked to ensure they are suitable to work in the home. Residents receive care from a service where the staff receive training. EVIDENCE: Residents receive a service from staff with a range of skills and abilities. On the days of inspection the staff on duty included the manager, registered nurse, care staff, domestics, activities organiser, catering staff and maintenance staff. The self assessment returned by the manager showed that the staff were from a range of ethnic backgrounds and this complemented the residents who were also from various ethnic and diverse backgrounds. Residents no longer get the benefit from two registered nurses on duty at all times. The home had made changes to its care staff mix. There were fewer registered nurses on duty than had been set out by the staffing notice. The staffing notice sets out the range and number of care staff to be on duty at Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 22 anyone time. The registered provider should have written confirmation supporting the homes intention to move away from the staffing notice. But a letter of understanding was not available. The home manager confirmed that he was the second trained nurse on duty. The provider needs to describe the action he will be taking to ensure that robust procedures are in place for covering the home when the manager is away. The home has one activities organiser. The manager was explaining that they had identified someone to assist the activities organiser. In order to assure us that the people who use the service get continuity we also need to know the robust arrangements for covering the activities service when the organiser is away from the home. Residents live in a home where the staff have been appropriately checked to ensure they are suitable to work in the home. Only one personnel file of recently recruited staff was reviewed and the information collected by the registered provider meet the standards. There was some concern that records which need to be available for inspection were in another office away from the home. A senior manager was able to give a satisfactory explanation. The personnel files of recently recruited staff were in another office because the contract of employment were being updated. Residents receive care from a service where the staff receive training and are currently going through a training programme provided by an external trainer. One training session was in progress on the day of inspection. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): We considered standards 37,38,39,42,43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home where they are supported in maintaining and improving a healthy lifestyle. Residents live in a home where safety checks are carried out on a regular basis. EVIDENCE: Resident live in a home where there has been a change in manager. The previous registered manager has been gone for over six months and the current manager has yet to be registered with us. However the manager is part of a service where the catering has improved, the domestic services are to a good standard and staff are receiving training. However the care documentation needs improving. The two professional staff who recently visited Brighbow, spoke well of the service provided to the residents. The Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 24 residents who contributed to this report spoke well of the staff and how the home was run, one resident said “I am quiet independent” another said “we can choose how we want to live”. Residents are asked for their views on the service they receive from the home. The home organises meetings for residents to express their views. Some of the residents already knew of plans to change the Lodge into 3 units. The self audit returned by the manager said that a quality monitoring system had been implemented. Residents live in a home where safety checks are carried out on a regular basis. The maintenance man could explain his routine for carrying out the health and safety checks and could show the records were up to date. The self assessment returned by the manager also contained the dates of when maintenance checks were carried out and these were up to date. The fire records showed that checks were being carried out. Residents could not be assured that their personal allowance money being looked after by the staff, is correct. Four of the resident’s petty cash accounts were viewed. In two of the four accounts, the cash balance recorded in the petty cash book did not balance with the actual money stored by the home. The reasons for these discrepancies to need to be looked into and a more robust system implemented. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 2 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 X X 3 2 Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 6(4) Requirement The statement of purpose and the service user guide need to be kept up to date and readily available. Care records need to have written assessments by the Brightbow staff to show that consideration has been given to ensure the home can meet the resident’s needs. The home needs to review its petty cash procedure to ensure that the resident’s petty cash is correct. Care records need to have daily entries to reflect the resident’s changing needs. Care records need to have written risk assessments to show that any potential harm to residents has been taken into consideration. Timescale for action 01/03/08 2 YA3 14(1)(a) 01/03/08 3 YA41 16(2)(l) 01/03/08 4 5 YA6 YA7 15(2)(b) 13(4)(c) 01/03/08 01/03/08 Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 27 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 YA33 Good Practice Recommendations The registered provider needs to provide robust arrangements in writing on how the absence of the registered manager and the activities organiser will be covered to ensure continuity of care for the people using the service. Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Brightbow Lodge & Brightbow Court DS0000020271.V352500.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!