Inspection on 18/06/08 for Bronte Park

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bronte Park 23/10/09

Bronte Park 12/06/09

Bronte Park 07/11/07

Bronte Park 24/01/07

Bronte Park 13/06/06

Bronte Park 05/10/05

Bronte Park 23/06/05

Bronte Park 14/02/05

Bronte Park 07/10/04

Bronte Park 29/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Bronte Park Bridgehouse Lane Haworth Keighley West Yorkshire BD22 8QE Lead Inspector Liz Cuddington Key Unannounced Inspection 18th June 2008 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bronte Park DS0000050797.V368470.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. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bronte Park Address Bridgehouse Lane Haworth Keighley West Yorkshire BD22 8QE 01535 643268 01535 647468 theheathersbrad@fsmail.net 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) Bronte Regency Healthcare Ltd Vacant Care Home 28 Category(ies) of Dementia (28) registration, with number of places Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 28 7th November 2007 Date of last inspection Brief Description of the Service: Bronte Park is a detached, converted property situated in the village of Haworth and is registered to provide nursing care for older people with dementia. The home is close to local amenities and public transport routes, although there is a long driveway leading up to the home. There is parking to the front of the property. The rear gardens are accessible to the people who live at the home and steps have been taken to make this a secure area. A side entrance provides disabled access into the property. The main house is a listed building with an extension to the rear of the property. The accommodation is on two floors, with access between floors via a stair lift. There are twenty-one bedrooms; fourteen are single rooms and seven are twin rooms. Some of the bedrooms have en suite facilities. There is a lounge and separate dining room on the ground floor. There are three bathrooms, one shower room and seven toilets in the home. The weekly fees are between £385 and £450. There are additional charges for personal items such as hairdressing, newspapers and chiropody. Bronte Park DS0000050797.V368470.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. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Bronte Park. The visit to the home was carried out over one day by one inspector, accompanied by an Expert by Experience. This is someone who has experience of using care services. Information from their report is included in this inspection report. The last key inspection was in November 2007. Following this we made a referral to Bradford Social Services’ Adult Protection team. Our concerns have been satisfactorily dealt with by the home’s management and Social Services’ staff. In April 2008 two inspectors visited the home to carry out a random inspection, focussing on issues raised with us by people who were concerned about the quality of the care provided at Bronte Park. The findings are detailed in a separate report, which is available on request. Three additional statutory requirements were made following the April inspection visit. These concerns gave rise to a further referral to Bradford Social Services’ Adult Protection team. The issues have either been not substantiated or have now been dealt with satisfactorily. At a Social Services Adult Protection meeting in May 2008, it was agreed that improvements are being made at Bronte Park and no further action was needed. The methods used to gather information during the visits included conversations with the people living at the home, their relatives and the staff, as well as looking at care plans and examining other records. We did not receive the home’s self-assessment questionnaire before this inspection visit. We would like to thank the people who live at the home, their relatives and the staff, for their welcome and hospitality and for taking the time to talk and share their views during the visit. What the service does well: Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 6 The atmosphere in the home is calm and welcoming and the interaction between the people who live at the home and the staff is friendly and relaxed. People who live at Bronte Park said the care is good and the staff are kind and helpful. Relatives said they are satisfied with the care. One relative said the staff are ‘very attentive’ and they are happy with the care that is given. The staff are aware of each individual’s needs and know how people prefer their care and support to be provided. The kitchen has recently had an Environmental Health inspection. It was given a four star rating, out of a possible five stars. The staff practice good hygiene and infection control, they wear protective gloves where needed and there is hygienic hand rub available. What has improved since the last inspection? What they could do better: Four requirements from the last inspection visits are still outstanding. To help staff provide the care and support people need, the care plans and risk assessments must be kept up to date and reflect each individual’s current assessed needs. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 7 To make certain that the care plans reflect people’s needs and preferences, individuals or their representatives need to read and sign the plans to confirm their agreement. The medication recording systems need to be improved, to make sure that all the medicines kept at the home are accurately recorded and accounted for. Although some improvements have been made in the range of activities the home provides, there is still more work to be done to make sure that everyone has the opportunity to enjoy social interaction and mental stimulation. For the safety of the people who live at the home, risk assessments must be completed for all assessed risks, including those areas of the home where smoking is allowed. To make sure people are properly protected, all the staff need to take the comprehensive adult protection training that is planned without delay, in addition to the introductory training they are currently offered. A programme of redecoration must be implemented, to make the home brighter and more attractive for the people who live there. More domestic staff must be employed in order to keep the home clean and odour free at all times. To protect people’s confidentiality, all personal records must be securely stored, in accordance with the requirements of the Data Protection Act. The Registered Provider must complete a monthly report, confirming that they have visited the home and are satisfied that the home is being run in the best interests of the people who live there. We must be kept informed of all significant occurrences at the home, in accordance with Regulation 37 of the Care Standards Act 2000. 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. Bronte Park DS0000050797.V368470.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 Bronte Park DS0000050797.V368470.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): 3 Standard 6 does not apply People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: Where possible the home encourages people and their families to visit and talk to the people who already live at the home and their relatives. People are welcome to come and spend time at the home, before reaching a decision. This means that the home’s staff can get to know the person’s needs and also the individual and their relatives have the information they need to help them make such an important decision. If this is not possible, a senior member of staff visits people in their own home or in hospital to carry out an assessment and make sure the home can meet Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 10 their needs before offering a place. The care plan files included the pre-admission assessments completed by the home and Social Services, where this applies. The assessments are very detailed and form the basis for developing the person’s individual plan of care and support. Bronte Park DS0000050797.V368470.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and healthcare needs are met. The care plans and risk assessments do not all reflect people’s current needs. People are generally protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: Three care plans were looked at, to make sure that people’s health and personal care needs are being met in the way each person prefers. The plans contain information to guide staff in how to care for and support each person. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 12 From observation and discussions with staff and people living at the home, it was clear that the staff are aware of each person’s needs and preferences. The staff make sure they provide the help and support people need in the way they prefer. One relative said the staff are ‘very attentive’ and they are happy with the care that is given. People who live at Bronte Park said the care is good and the staff are kind and helpful. Relatives said they are satisfied with the care. People said that they receive the medical and healthcare support they need. Where needed, we saw that a pressure care plan was in place. This detailed the treatment that was needed and showed how the wound was progressing. The tissue viability nurse was involved in developing the plan and making sure the treatment plan was being followed. Where they are needed, pressure relieving cushions and mattresses are used. This makes sure that when people’s skin is delicate, any risk of soreness is minimised. People who need assistance with their mobility have a moving and handling plan. Where needed, specialist care and support plans are in place detailing what the person wants and has agreed to in order that staff are able to assist people effectively and in the way they prefer. Some of the information in the plans was not up to date. For example, there was no information to show that the daytime care plans had been reviewed regularly, to make sure they still reflected the person’s needs. We did see evidence that the night care plans were being reviewed and updated every month. Two plans contained information about people’s assessed risks that was out of date and did not reflect the individuals’ current care and support needs. To help staff provide the proper care and support, it is important that all the plans and risk assessments are up to date and reflect each individual’s assessed needs. The care plans also need to show that, where possible, individuals and their families or their representatives are involved in developing and reviewing their plans. There was evidence to show that some people’s placement at the home had been recently reviewed by Social Services and they were satisfied that the home can still meet their needs. The medicines are usually kept safe and secure and the Medicines Administration Record (MAR) charts are securely stored. For security, the Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 13 medicine cabinet was locked during the time between giving each person their medication. The MAR charts, which must show clearly the quantities of medicines received and in stock for each person, were examined The medicines appeared to be administered and recorded accurately. There were signatures to confirm that staff had administered the medicine. However the nurse on duty at the time of the visit, who was not one of the home’s permanent staff, did not sign each dose at the time it was administered, but signed all the MAR charts together after administering all the medication. This is potentially unsafe and could result in errors being made. At one point in the day, some medicines were left on a shelf in a room that was not locked. This is unsafe practice. A check of the quantities of some of the medicines administered, compared with the amounts received and in stock showed that the medicines records did not accurately show the total amounts in stock. A brought forward system needs to be put in place, when medicines are carried forward from one recording period to the next. The MAR charts must clearly show how much of each medication the home has in stock. Any controlled drugs are safely stored in a locked cabinet in a locked room. A separate record book is also kept that two staff sign each time a dose is administered, to confirm that the quantities administered and remaining are accurate. There were some medications in the controlled drugs cupboard that should have been disposed of, as they were no longer needed. The remaining quantity of one of these did not tally with the amounts showing in the record book. During the visit, all the staff were seen to treat people with respect and maintain their dignity. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. People’s relatives confirmed this. Everyone said the staff listen and act on what they say. Bronte Park DS0000050797.V368470.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in some activities. People are offered a choice of meals to make sure their dietary needs and preferences are met. EVIDENCE: The staff provide some activities for people to take part in, if they wish. People said there were things to do, but they would like more. The management is aware that this is an area where improvements can be made. On the morning of our visit the new music system was playing pleasant background music. In the afternoon the television was also on for some of the time, but with the sound turned off. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 15 Many people sat for a very long time in the morning with no stimulation. With the staffing levels the home has in place, it should be possible for there to be at least one member of staff in the lounge most of the time. At present the activities include singing and music, karaoke, dancing, board games and other activities that people choose. Trips out are also arranged, for individuals as well as groups. Each person is now registered to use the Access bus so they can go further afield, if they wish. Some day trips on the Keighley and Worth Valley steam railway have also been arranged. Some people like helping in the garden and we were told there is croquet and other outdoor games available for people. A member of staff is delegated to arrange the social activities each day from around 2pm. The session we saw was not well prepared, and not enough was done to stimulate interest in more than a few people. It is very difficult for one person to implement social activities on their own for people whose attention span may be quite short. Activities need to be well organised with other staff taking an active role. For many people group activities are not appropriate. Staff may find it better to spend time with people in one to one activities, such as looking at their family photos, reading a paper or magazine or tidying their clothes drawers together and having conversations. We were told that a man visits monthly and entertains people by singing with a guitar accompaniment. The local vicar brings communion every month for those who want to take part. There were activity record sheets in some people’s care plans, but one of them had not been completed since early in March 2008. If these are to be used to keep a note of the activities people like to do, then they need to be completed on each occasion. A four-week menu plan is available. The daily menu is written on a board in the dining room, together with the names of the staff on duty that day. The menu looked good with cereals and a cooked choice at breakfast, and a two-course meal at lunchtime. There was no choice offered at lunchtime, but if someone did not want what was on offer an alternative would be provided. Drinks are available throughout the day. We were told that people are usually asked before the meal what they would like, but we saw no evidence of this during this visit. A few people were given protective plastic aprons to wear during lunch, and this was done in a kind, respectful manner and with their consent. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 16 The size of the dining room does not appear adequate for the number of people. One person came into the dining room looking for a place, but had to be redirected to the lounge. In the lounge some people stayed in their chairs and had lunch served to them on individual tables, one person sat at the centre table in an arm chair which was too low and they looked to be having difficulty managing. If people are eating in the lounge, appropriate height tables and chairs need to be provided for everyone. People said they enjoyed their meals and staff were on hand to discreetly assist people who needed some help and to gently encourage people to finish their meal. The tables were laid with tablecloths, paper napkins and cutlery and drinks of juice and tea were provided. Visitors are always welcomed to the home. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 17 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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received some training and understand the adult protection procedures, which makes sure that people at the home are safe. EVIDENCE: Since the last key inspection in November 2007, there have been two referrals to Bradford Social Services’ Adult Protection Unit. These arose from concerns that were raised with us about the quality of care provided at Bronte Park. Since then the issues that were brought to our attention have been resolved and improvements have been made. Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. A copy of the complaints procedure was not readily available when requested. Staff said they know what to do if anyone has concerns. The relatives said the home responds appropriately to any concerns they have. Most people said they Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 18 know what to do if they have a concern or complaint. Newly employed staff are made aware of the home’s ‘whistle blowing’ policies and procedures, to be used if they suspect abuse or see examples of poor practice. The majority of care staff have had basic adult protection awareness training, and further training through Bradford Social Services is planned for all staff this year. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 19 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, 20, 24, 25 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe, comfortable environment. EVIDENCE: The home is quite well maintained, although much of the paintwork is in need of attention, mainly through becoming scuffed by wheelchairs. The lounge is a pleasant, light and spacious room. It is nicely carpeted and the armchairs are in a reasonable condition. The hall carpet has become badly marked from the wheelchair tyres. The ground floor rooms looked clean and fresh, but the domestic assistant had not had time to clean upstairs. Some of the bedroom carpets looked dirty, stained and shabby and most of the upstairs bedrooms needed a thorough Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 20 clean. There was a smell of stale urine in some of the bedrooms. The domestic assistant said she was going off duty at 1:30pm, having started work at 9:00am. At the time of our visit there was only one person employed to keep the house clean. The management assured us that one member of staff had recently left and they would be recruiting for another domestic assistant. All the bedrooms had a commode and most had bedside lockers and dimming light switches for night time. Each bedroom reflected the person’s individual taste. Soft toys, photographs and other personal items were very much in evidence. Some people have their own TV and music centre in their rooms. There are plans in place to install a shaft lift. This will be done as soon as planning permission is granted. Afterwards the providers told us they will be re-decorating and they have plans for making further improvements to the home. One person’s relative also said they thought parts of the house need to be re-decorated, in order to make the home brighter. There is a patio area to the front of the house, which was being improved with more seating and pots of colourful plants. The back garden is safe and well maintained, with seating for people to use when the weather is good enough. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet people’s needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided, or has been planned, to make sure staff have the skills and knowledge they require in order to meet people’s needs. EVIDENCE: The staff rotas confirmed our observations that there are enough staff on duty to meet people’s care, social and leisure needs. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. Staff confirmed that they have training opportunities to support them in their roles. Staff said their training was relevant, helped them understand their role and kept them up to date. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 22 Four of the care staff have started a suitable National Vocational Qualification (NVQ) in care at level 2. Four of the other care staff qualified as nurses in their own country. All new care staff take induction training which meets the Skills for Care criteria. This gives them good training to help them do their job effectively, and provides a good basis for taking an NVQ course. Currently all staff take the mandatory health and safety and basic adult protection training, and have regular refresher training to keep their knowledge and skills up to date. In addition staff training planned for this year includes alcohol misuse, medicines administration, and care planning. Some staff have taken a course in palliative care and all staff are to have training in how to manage challenging behaviour. Some staff are to take courses in stroke awareness and bereavement. An introduction to mental health training course is being taken by staff, who can choose which modules they feel would be most beneficial for them. We were told that all the staff are taking a dementia awareness distance learning course through Park Lane College, Leeds and that all the staff have had training in the Mental Capacity Act and malnutrition awareness. During the inspection two dental care professionals came to the home to deliver training to staff on oral hygiene and mouth care. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 23 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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe, but a qualified and experienced manager is needed to make sure the home is effectively managed in the best interests of the people who live there. EVIDENCE: At the time of the inspection visit a new manager had been appointed and was expected to take up the post in the first half of July 2008. Any financial transactions the home does on behalf of people who live at the home are accurately recorded and receipts are kept. Any monies held for people are securely stored. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 24 The records, and the staff, confirmed that all staff are now having regular one to one supervision meetings with their line manager. This supports staff to plan their personal and professional development and gives them the opportunity to discuss any areas of concern in a confidential setting. People’s personal information is stored in an office, which was not always locked when it was not being used. As this information is confidential it is important that the door is locked, or the information made secure, when the room is not occupied. To protect people’s confidentiality, all personal records must be securely stored in accordance with the requirements of the Data Protection Act. The home’s kitchen has recently had an Environmental Health Officer’s inspection. The kitchen was awarded four stars and, when we looked, the kitchen was clean and hygienic. Observations confirmed that the staff practice good hygiene and infection control. They wear protective gloves and aprons where needed and there is hygienic hand rub available. For the safety of the people who live at the home, risk assessments must be completed for all assessed risks, including those areas of the home where smoking is allowed. The Registered Provider must complete a monthly report, confirming that they have visited the home and are satisfied that the home is being run in the best interests of the people who live there. A copy of this report must be made available to the Commission on request, in accordance with Regulation 26 of the Care Standards Act 2000. We must be kept informed of all significant occurrences at the home, in accordance with Regulation 37 of the Care Standards Act 2000. Bronte Park DS0000050797.V368470.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 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 2 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 2 2 3 X X X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 26 YES 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 OP7 Regulation 15(2)(b) Requirement To support staff to provide the care and support people need, the care plans must be up to date and reflect people’s current needs. Risk assessments must also be up to date. To make sure that people are receiving the care they need, the resident’s, or their representative’s, agreement to the care plan must be obtained where possible. (Previous timescales of 31/03/07 and 17/04/08 not met). For the safety of the people who live at the home, the medicines records must be completed at he time the medicine is administered and packs of medicines must not be left in an unsecured area. A wider range of activities must be provided to stimulate people with a diagnosis of dementia, on a group and individual basis both DS0000050797.V368470.R01.S.doc Timescale for action 30/09/08 2. OP7 15(2)(c) 30/09/08 3. OP9 13(2) 31/07/08 4. OP12 16 (2)(m) & (n) 30/09/08 Bronte Park Version 5.2 Page 27 in the home and outside. (Previous timescale of 17/04/08 not met). To keep the Commission for Social Care Inspection informed of significant occurrences within the home, a Notifiable Incident form must be completed and sent to the Commission whenever a significant incident occurs. (Previous timescale of 17/04/08 not met). For the safety of the people who live at the home, risk assessments must be completed for all assessed risks, including those areas of the home where smoking is allowed. 5. OP31 37 31/07/08 6. OP38 13(4) 31/08/08 7. OP38 26 (Previous timescale of 17/04/08 not met). The Registered Provider must 30/06/08 complete a monthly report, confirming that they have visited the home and are satisfied that the home is being run in the best interests of the people who live there. A copy of this report must be made available to the Commission on request. 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 OP9 Good Practice Recommendations In order to keep an accurate record of all the medicines that are supplied in their original packaging, a ‘brought DS0000050797.V368470.R01.S.doc Version 5.2 Page 28 Bronte Park 2. OP12 3. 4. OP37 OP38 forward’ system for recording the amounts carried forward and in stock should be introduced. The manager should make sure that people’s personal history and activity records are fully completed and used by staff to inform them of people’s individual likes and preferences. This information should then be used to plan activities according to individual needs. To protect people’s privacy, confidential information should be stored securely at all times, in accordance with the Data Protection Act 1998. The home’s policies and procedures should be updated to reflect the scope of the current service and to provide guidance for staff. Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Bronte Park DS0000050797.V368470.R01.S.doc Version 5.2 Page 30 - 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!