CARE HOMES FOR OLDER PEOPLE
Bronswick House 16/18 Chesterfield Road Blackpool Lancashire FY1 2PP Lead Inspector
Mrs Jackie Riley Key Unannounced Inspection 8th April 2008 09:15 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 Bronswick House DS0000009843.V361614.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. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bronswick House Address 16/18 Chesterfield Road Blackpool Lancashire FY1 2PP 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) 01253 295669 Mrs Savitree Seedheeyan Ms Christine Allen Care Home 14 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (12) of places Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 14 service users to include up to 12 service users in the category of MD (Mental Disorder) up to 2 service users in the category of DE (Dementia) 11th October 2007 Date of last inspection Brief Description of the Service: Bronswick House is registered to provide residential care for fourteen residents with a Mental health illness. The home is set on two floors with three residents rooms on the ground floor and ten on the first floor. There is one double room situated on the ground floor. There are no en-suite facilities. The first floor is accessed by three sets of stairs. There is assisted access to the first floor of the home, however most residents living on the first floor have good mobility. The home is situated in a residential area, and is close to the public transport network. There is a good transport network into town, and also local shops. A Statement of Purpose and Service User Guide is available providing information about the home. The information can be used by relatives/representatives to help them make an informed choice whether to move into the home. At the time of the site visit the range of weekly fees were £279.00 to £360.00. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes.
This was an unannounced visit to the home that took place on the 08/04/08 as part of the key inspection. We spoke to the provider, manager, staff members, and 6 residents; there were no visitors to the home. As part of the inspection process we talked to people using the service and asked staff about those peoples needs. We also looked at their rooms, care plans, records and daily notes this is called case tracking. Other residents are invited to pass their opinions to us if they wish. We had responses from surveys/questionnaires sent to relatives and residents for their views on how the home is run. Comments were generally positive and some are included in this report. Every year the person in charge or manager is asked to provide us with written information about the quality of the service they provide, and to make an assessment of the quality of their service. We use this information, in part, to focus our inspection activity. We looked at three residents records, recruitment and training records of two staff members. We also spent time in the lounge areas, walked around the building and watched people living and working to see how everyone was supported and talked to each other. What the service does well:
The way the home is run is flexible for the needs of the people who live there. There are no rules, which may restrict residents in what they choose to do on a day-to-day basis. Comments included, “The staff are very caring, capable and aware of the needs of the residents”, “Its nice to be able to make yourself a drink whenever you want to”, “we can get up and go to bed when we want to really, there’s no rules” We found the manager and staff members try to make sure residents needs are met in a way which is not intrusive, so that they feel they can live their lives in a way in which they choose, with restriction only being in place based upon their safety and well being. “we want people to live the way they choose to unless it would be too risky for them, or if it were to affect other people”.
Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 6 We saw staff assisting residents to do things in a sensitive manner so that resident’s privacy and dignity are respected. “we try to make sure people living here are respected for who they are”. What has improved since the last inspection? What they could do better:
We found the information contained in individual care plans was limited and varied therefore staff may not have all the information they need to provide care. There was no evidence reviews of residents needs are taking place on a regular basis, thereby staff are limited in their knowledge about changes which may have occurred resulting in changes to the level of care a resident might need. We found that whilst a fire risk assessment was now in place it was not signed or dated and the fire handbook included old information, which must be reviewed and updated so that people are protected. Records showing staff training in this area were blank, although staff spoken to said they had all received training in fire practice. The manager told us the fire brigade have been asked to provide a fire talk to the staff team in the next few weeks, staff spoke to confirmed this. Work to decorate and replace old and worn carpets is required in the smoking lounge, conservatory area, dining room. Other areas of the home require general decoration to make the environment a bright and fresh one for residents to live in. A carpet fitter and decorator arrived at the home during the inspection to arrange for the replacement of carpets and decoration of the smoking lounge and dining area. We were told this work would be carried out with immediate effect and would take approximately two weeks to complete. We found the designated smoking lounge has limited ventilation, which makes it unpleasant when being used by a number of residents at the same time. There must be adequate ventilation in this area for the health and welfare of users of this area and also for the staff team.
Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 7 Staff working at the home as bank staff, have previously worked at the home on a permanent basis. We say these staff must have updated fitness checks including current references so that all users of the service are protected. We saw maintenance certificates including electrical, gas and the lift were out of date, however an electrician was working at the home and told us the work is currently being carried out. Certificates for maintenance must be up to date for the health and safety of all stakeholders of the service. Many of the records we looked at were disorganised and hard to follow. These records should be reviewed and put in order so that staff have clear instructions to follow. Records recording risk have been improved however they must show how an identified risk is going to be managed for a positive outcome for the resident. We looked at activities and found whilst many residents like to do their own thing, there is very limited choice in respect of activities arranges around the needs of residents living at the home, so they may be disadvantaged in respect of recreation. We found little evidence of a formal quality review process which would take into account residents or other stakeholders views including relatives and other professionals, which could be used to measure how the service is performing and make any necessary changes. There is currently no formal supervision programme in operation for staff, which would help them to develop in their individual roles and for their professional development; this is an area, which should be developed. 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. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission and assessment procedures are in place so the home can meet individual needs, EVIDENCE: We looked at the records of three resident’s, they had assessment details recorded, so that staff had a good insight into what the needs of residents are and how they will be met. In all instances we found the home is receiving a thorough assessment plan from the placing authority. We talked to the manager who stated she always visits a prospective resident prior to admission to the home to make sure the home is suitable to meet the needs of the resident. We spoke to a resident who was admitted recently and confirmed this was the case. “Yes, they came to see me before I came here”.
Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 10 The records we looked at all had individual contracts in place and were signed by the resident, however in one instance this was not the case. By discussing the issue with the manager it was confirmed this was due to the short time the resident had been in the home, based upon a trial period. A resident spoken to said, “I remember signing a contract, it’s for staying at this home”. Standard 6 was not assessed, as Bronswick House does not provide intermediate care. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. There is limited information in care plans, which has the potential to disadvantage people living at the home. EVIDENCE: We looked at three care plans. They were found to include basic information about the residents needs. We saw thorough assessment placement plans, which are used to base the level of care provided to individual residents. Whilst the health and social work assessment plans are comprehensive, there is a need for the home to produce its own care plan based upon the needs of the resident in the care home. We found the way files are managed, are disorganised with loose pieces of paper, and no sequential order, which makes it difficult for staff working with the file to be able to follow the information clearly. We spoke to the manager
Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 12 about having a system where all the information is collated together thereby providing a simple and effective system to work by. There has been some development in how risks to residents are managed. The risk assessment now takes into account environmental risk, however this is limited and should be extended to include how risks identified are going to be managed. In one instance no risk was identified but advised to “look at later”. No date for review was evident, which means staff may be missing situations which could be monitored and measured. Service Users care reviews are conducted in an informal way. One resident said, “they come and have a chat about how I’m getting on”. We saw staff use a daily recording system and summary system, which accounts for any changes taking place or things which may affect a resident. This is used as part of the care planning and review process. There needs to be a more unified way in which to manage care planning so that on going assessment and review can be seen in the records to give a consistent picture of the changing needs of the residents and how the home is responding to those changing needs. We found there are a number of residents who require regular health support. We saw this is occurring and residents are supported to attend appointments and receive the healthcare support they need. Comments included, “they are really good whenever I need to go to the hospital they help me”, “we know the residents well enough to know when they need support”, “they’ve been really good since I’ve been ill, they can’t do enough for me”. We saw staff speak to residents sensitively and with respect. Staff we spoke to are aware of the need to make sure residents rights to dignity and privacy are maintained. They were seen to knock on doors before entering. We found the ground floor resident’s toilet had a broken lock, which might impede a resident’s privacy and dignity; we discussed this with the manager who stated it would be repaired at the earliest opportunity. We looked at how the home manages the medication system for storage and administration. Since the last inspection when the home was asked to look at improving the storage facilities, there is a locked medicines cabinet situated in the dining room and secured to the wall for the safe storage of all medications used in the home. Staff said it has improved how medication is stored and managed. We looked at the medication records of the three people we were Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 13 following during the inspection process. There medication records were complete and recorded well, by staff who have received training in medication administration and recording. There is a returns book, which showed the manager is making sure medication which is not used is returned to the pharmacist so that there is no excessive storage of medication in the home. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Daily life and social activities are designed to be flexible to meet the needs of people living in the care home, however lack of an activity programme means it is not in the best interests of the people who live there. EVIDENCE: We found the routines in the home are flexible to meet the needs of the people who live there. We saw some residents choose to get up later in the morning, whilst other residents choose to stay in their rooms for most of the day. Other residents we saw and spoke to prefer to take their meals in their own rooms, or go out when they choose and have their meals when they return. This was no problem to the staff team, who said meals and mealtimes are flexible. Staff spoken to say they acknowledge peoples rights to choose how they live their lives. Residents comments included, “Its nice to be able to make yourself a drink whenever you want to”, “we can get up and go to bed when we want to really, there’s no rules” Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 15 We saw the homes food is prepared on the premises by members of the staff team. The lunchtime meal was seen to be suitably balanced with choice available to residents who do not wish to have the menu option on that day. We spoken to the manager about nutrition, and were satisfied that there is a good understanding of the need for residents to have a balanced diet, using fresh produce wherever possible. Residents spoken to commented on how they like the meals and said, “If I don’t like something Ill tell them and they find something else for me”, “If I’m out they keep it form me when I get back, there’s no problem”. We found there is no formal approach to activities in or outside the home. We saw a number of residents using their own rooms, and whilst this is their choice there is little stimulation in respect of group or individual activities arranged. Staff should be using the assessment profiles to gain an insight into what residents liked to do before they came into the home, and to use this information as a basis to identify suitable activities, which would enrich their social activities. Some of the comments we received included, “Satisfied with all areas except arrangements for activities there are none to take part in”, “Satisfied with all areas except lack of activities”. We spoke to three residents who like to live their lives as independently as possible, and this includes going out daily. “I still like to go out everyday, it keeps you fit”, “ Go out whenever I want, but I always tell the staff so they know where I am”. A number of residents like to sit in the smoking lounge on the first floor. We saw this lounge is used most of the day, as this is the designated room where people can smoke and most of the residents living in the home smoke. Comments included, “ we have a chat in here where we can enjoy a ciggie together”. We say consideration should be given to extending the choice of activities to residents so that they can make an informed decision about what activities they would like to be involved with. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. The arrangements for recording and reporting of complaints are good ensuring people feel listened to. Staff have access to safeguarding adults training for the protection of users of the service. EVIDENCE: The home has a complaints procedure, which is made available to them or their relative or advocate during the admission process. Six surveys confirmed they are aware how to make a complaint, One comment said, “ I have direct contact including the mobile phone number of the manager”. The staff team confirmed they know how to deal with complaints and we found there is an open system of communication so that any concerns raised are dealt with by the manager at the time of the concern. There should be more documentation on individual files when concerns have been raised so that there is evidence of what action has been taken to rectify any concerns. Comments included, “we encourage residents to say if they are not happy about something so that we can put it right”. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 17 There has been one complaint received by the Commission in the previous twelve-month period. The management team investigated the complaint and the issues were addressed and the Commission was notified of the outcomes. The home has a procedure in place for dealing with allegations of abuse. Staff spoken to are aware of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect, and have received training in this area. Staff comments included, “we’ve have had training for it, so we know what to look out for and what to do”. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 18 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): 19,21,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is designed to be homely, however due to lack of maintenance it has the potential to be detrimental to residents living there. EVIDENCE: We looked around the home. It is designed to be homely and comfortable for residents to live in. There are limited aids and adaptations due to the independence of the residents living at the home, however there is in place a stair lift for access from the ground floor to the first floor, although this is not used. “We keep fit by using the stairs” was one comment. All residents have their own rooms, which we saw to be personalised, and some residents said they like to use their rooms whenever they choose. One
Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 19 resident said they like to make themselves tea, toast in their own room as it makes them feel more independent. We saw there are enough bathing and toilet facilities in place to meet the needs of the residents living there, however the lock in the ground floor toilet was broken and requires repair so that people privacy is upheld. We found there are a number of areas in the home which require urgent maintenance, they included, the dining floor covering and decoration, the conservatory passage, flooring and leak repair, the first floor smoking lounge in urgent need of decoration and replacement for worn and heavily stained carpet, ventilation equipment for the smoking lounge and general decoration around the home. Whilst at the home carrying out the inspection a decorator and carpet fitter visited the home to commence work. We spoke to them and they confirmed they are carrying out work with immediate effect on all areas identified. We also noted under the bay window of the front lounge there is plaster missing, this needs attention to make sure the home is maintained to a satisfactory standard. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. There are procedures in place for staff recruitment however bank staff who have previously worked at the home do not have updated fitness checks in place having the potential to pose risk. Staff have access to training so they can provide a good service to residents. EVIDENCE: We found there have been no changes to the staff team since the previous inspection. We spoke to the manager who said the staff are flexible in how they work, and some bank staff are currently working at the home. They are staff who have previously worked at the home on a permanent basis. When we looked at the staff files we found there have been no updates in the staff fitness checks including references. This must be carried out so that people are protected. We talked with the manager and home owner about staff training. We found the staff team have all attained vocational qualifications at various levels, and other qualifications in meeting the needs of residents who live at the care home. We were told there are designated trainers and a designated training facility available to staff. Staff members spoken to said they attend training
Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 21 sessions on a regular basis. Comments included, “we go on training courses, and we’ve all got different levels of NVQ’s”. We made observations of the way staff and residents mix and found residents responded well with staff members. Staff members showed understanding and sensitivity in how they communicated and assisted residents with various tasks, so that it was a good outcome for the people who live there. We received some comments about how the home is staffed, they said, “not enough staff to cover for emergency/sickness etc, but the staff available are very competent. We looked at how the home is staffed and found there is a manager in day to day control and two care staff on duty. We say there are sufficient numbers of staff on duty, however if residents need assistance outside the home there would need to be additional cover to meet the needs of residents living at the home. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is inconsistency in the management of the home, having the potential to affect the level of quality in the way the service is delivered. EVIDENCE: The manager of the home has the knowledge, experience and qualifications to undertake the day to day control of the home. We looked at how the home is managed by looking at records and systems in place. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 23 We found there is flexibility in how the home operates, so that people living there can make their own decisions, which is acknowledged by the manager and staff. We talked to the manager about staff supervision. We were told there is a current review of this and that a system is to be introduced shortly to supervise all staff. We say staff should feel supported through a supervision system, which will look at performance and development and to record this so that there are measurable aims and objectives for staff to work towards for the benefit of staff and residents. We looked at how the home measures its stated aims and objectives using quality monitoring and found this is limited to staff meetings and informal resident comments. There must be some formal way of collecting information about the homes performance so that it can be evaluated in order to make sure it is being run in the best interests of users of the service. We looked at the maintenance records for the home and found electric, gas and lift certificates were out of date. This was discussed with the manager and provider and action was taken to address this issue with immediate effect. We spoke to the visiting electrician who informed us of the immediate work being carried out to address these issues. We say there must be evidence maintenance of services in a home must be consistent so that the health, safety and welfare of people living at the home is protected. We looked at the fire systems and records. We found the systems have been serviced and are in date. The manager informed us the fire brigade have agreed to provide training in the near future to update staff. The fire record book we looked at was out of date in some areas, it was disorganised, and whilst a fire risk assessment was included it was not signed or dated. We say this must be reviewed and documents signed so that there is the availability of an audit trail, and that reviews can be determined. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 25 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(1)(b) Requirement Timescale for action 31/05/08 2. OP7 3. OP10 4. OP12 5. OP19 All residents must have in place a service user plan, which clearly identified their individual needs and how they are going to be met, and to review that service user plan on a regular basis so that changes can be identified. 13(4)(b)(c Whilst risk assessments have ) been improved they must show how an identified risk is going to be managed so that people are protected. 23(2)(b) The lock on the ground floor toilet must be repaired to make sure residents privacy and dignity can be met. 16(2)(m) The home must make sure they provide choice in activities suitable to meet the needs of residents living at the home, so that they have a varied choice. 23(2)(b)(c Maintenance of the home must )(d)(p) be improved including replacement floor covering in the dining room, Conservatory, first floor lounge, decoration of dining room and smoking lounge, repair leak in conservatory, repair plaster work under front lounge
DS0000009843.V361614.R01.S.doc 31/05/08 30/04/08 31/05/08 31/05/08 Bronswick House Version 5.2 Page 26 6. OP29 19(1)(a)( b) 24 7. OP33 8. OP38 23(b)(c) 9. OP38 17(2)(3) window, provide adequate ventilation to smoking lounge, for the health welfare and comfort of people using the service. Bank staff must have updated fitness checks including updated references to make sure they are suitable to work with residents. There must be a system of review for the service in order to improve areas identified as necessary for the benefit of all stakeholders. Maintenance of electrical systems, gas and lift equipment must have regular servicing in order to comply with health and safety regulations and so that systems are safe for the protection of all users of the service. All records maintained by the home and referred to in Schedule 4 of the Care Home Regulations 2001 must be kept up to date so that they can be easily accessed. 31/05/08 31/05/08 25/04/08 31/05/08 Bronswick House DS0000009843.V361614.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. 2. Refer to Standard OP36 OP38 Good Practice Recommendations All staff should be receiving formal supervision on a regular basis so they feel supported in their individual roles. The fire had book should be reviewed so that all loose leaf paper is put into sequential order and updated so that staff can follow the advice and guidance clearly. Bronswick House DS0000009843.V361614.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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