Inspection on 07/11/07 for Bronte Park

This inspection was carried out on 7th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Bronte Park 23/10/09

Bronte Park 12/06/09

Bronte Park 18/06/08

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bronte Park Bridgehouse Lane Haworth Keighley West Yorkshire BD22 8QE Lead Inspector Liz Cuddington Key Unannounced Inspection 7th November & 6 December 2007 12:30 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.V354349.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.V354349.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 Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places Bronte Park DS0000050797.V354349.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 categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 28 24th January 2007 2. 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. None 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.V354349.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection of the home took place on 24 January 2007. Following that inspection we asked the owner to provide an improvement plan to show how they were going to meet the requirements in the report. This was not received. The registered manager resigned in October 2007. We were not informed of this by the owner, which is required, as we need to be assured that suitable management arrangements are in place. The area manager is currently managing the home temporarily. Since the last inspection the owner applied to us to vary the registration categories, so the home can now admit people with a diagnosis of dementia who are under 65 years old, as well as people over that age. This purpose of the inspection was to make sure that the people who live at Bronte Park are receiving the care and support they want and that they and their families are satisfied with the service. The first inspection visit was over two days and lasted a total of ten hours and forty-five minutes. We then received a complaint, which resulted in a further visit by two inspectors over five hours. The methods used to collect the information needed included providing questionnaires for the people who live at the home and their relatives to complete. No completed questionnaires from relatives or from the people who live at Bronte Park have been returned. Before the inspection, a self-assessment questionnaire was sent to the home for the manager to complete before the visit. This has not been returned. Conversations with social care professionals about how they view the service provided for their clients provided useful information. During the visit to the home we spent time talking to the people who live there, the visitors, staff and management. We also looked at the information about how people’s care and support is provided and examined the home’s records. Since the last inspection there have been two adult protection issues, both of which were reported by the home to Social Services, although not to the adult protection co-ordinator. One was reported to us. Social Services’ staff have reassessed the people’s care needs and taken appropriate action. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 6 The findings of this inspection resulted in a safeguarding referral to Bradford Social Services, and a strategy meeting was held. The home’s acting manager, registered providers and other health and social care professionals, reached an agreement about the best way for the home to meet the needs of everyone at Bronte Park. We would like to thank the ladies and gentlemen who live at the home, their relatives and the staff, for taking the time to talk to us during the visit. What the service does well: What has improved since the last inspection? What they could do better: Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 7 Before a service is provided, comprehensive pre-admission assessments must be completed in every case so the home is certain that the individual’s needs can be met. The care plans must contain sufficient detail so that staff know how to meet people’s needs and manage behaviour. People, or their representatives, should be involved in the care planning process to make sure the person’s wishes and preferences are central to the planning process. Risk assessments for all potential hazards or risks must be completed, to show how potential risks could be minimised. The medication recording systems need to clearly show the quantities of all medicines in stock, so that staff always know the amount of medicines that are in the home. The home’s management and staff must explore ways of providing a wider range of activities that people will take part in and enjoy. The facilities in the home need to be improved with, for example, a second lounge to provide a better environment for the people who live there. The odour in the home’s entrance and in one of the bedrooms must be eliminated. The bathroom mentioned in the report needs some repairs and equipment should not be stored in it. Wash hand basins must have soap provided. The staff must complete essential health and safety training, and other training to keep their skills and knowledge up to date, in order to make sure that people are protected and the home has a well-trained staff team. Nursing staff with specialist skills in mental health must be recruited to make sure that people receive the specialist care they require. An immediate requirement notice was left requiring the staffing levels to be increased, which was actioned within the timescale set. Essential safety checks to equipment, such as the annual stair lift check, must be completed within the due time. The policies and procedures need to be kept up to date to reflect the scope and needs of the service and guide staff on how to act in each situation. 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.V354349.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.V354349.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are not always assessed before they move in, which means that the home may not be able to meet their needs. EVIDENCE: Some people’s care plans had a pre-admission assessment completed before they moved to the home. Other people had no assessment in their care plans. Some people also had a Social Services assessment of need, completed before they moved to Bronte Park, while other people did not. It is essential that before someone is offered a place at the home senior staff visit the person at home or in hospital, to assess their needs and make sure the home can meet those needs. People should also be invited to visit the home and spend time there before reaching a decision, whenever this is possible. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 10 Recently people have been admitted to Bronte Park who have not been assessed before moving in. Their care and support needs are very different from the other people who live at the home. One person who was admitted recently hit an older person and, for the safety of other people, had to then move somewhere else. Other people with behavioural problems have moved in recently, although at present there does not appear to be any risk to other people living at the home. One person has moved to Bronte Park from a home where they could no longer manage the individual’s behavioural challenges. To provide a safe, stimulating and suitable environment for everyone who lives at the home the staff need to have the training, skills and experience to support them. Bronte Park DS0000050797.V354349.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 health care needs are being met, however some people are not receiving the specialist care they require from staff. People are not fully protected by the medication recording and accounting systems. Staff treat people with respect and care at all times. EVIDENCE: The care plans cover each area of the individual’s health and care needs but do not contain sufficient detail. There are risk assessments in place that show how potential risks could be minimised but these do not contain sufficient detail to inform staff of the action they need to take to keep people safe. For example, there are some people who use language or display behaviour that is distressing to other people living in the home and there are no clear instructions for staff about how to manage this situation. From our Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 12 observations it was clear that on some occasions staff did not know how to deal with situations that arose. Each person who needs assistance with his or her mobility has a moving and handling plan. Details of visits by GPs and other healthcare professionals are kept. The care plans and risk assessments do not show that they are developed and regularly reviewed with each individual, and their family or representative if they wish, to make sure the person’s wishes and preferences are central to the planning process. The staff were seen to treat people with respect and maintain people’s dignity. People said that they receive the care they need and are supported to maintain their independence for as long as they are able. The relative of one lady who lives at the home, said she was satisfied with the care and said the staff are always kind and considerate. It was clear that the staff are aware of most people’s needs and preferences and make sure they provide the help people need in the way they prefer. However, there was no evidence to confirm that the staff are fully aware of how to meet the needs of some people who have recently moved to the home who do not have a diagnosis of dementia, but have other very different care and support needs. Medicines are kept safe and secure, although the medicine cabinet is very full. A second cabinet would make medicine administration easier and reduce any risk of error. The Medicines Administration Record (MAR) charts were examined. These must show clearly the quantities of medicines received and in stock for each person. This is done for the solid medication that is received from the pharmacy already dispensed into a monitored dosage system. But for medicines received in their original bottles and packets there is no ‘brought forward’ system in place, making it impossible to reconcile the quantities of medicines in stock with the amounts remaining and the quantities administered. Staff must sign the MAR charts each time they administer a dose of medicine, to confirm that the person has been offered their medicine. This was not being done on every occasion. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 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 maintain their independence and keep in contact with family and friends. Some leisure activities are provided to try and meet people’s social and recreational needs. People are offered a choice of meals, which meet their dietary and personal needs and preferences. EVIDENCE: The atmosphere at the home is warm and friendly and people’s families and friends are always welcomed when they visit. One visitor confirmed this during our conversation. Each person is treated as an individual and his or her choices and wishes are respected. People are supported to continue with their preferred activities, such as listening to music, going out to socialise, attending church and going shopping. The home provides some activities but there needs to be more variety and more regular choice of activities available. The staff also need to be aware of Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 14 how to engage people in activities that are stimulating and capture people’s attention. During the visits, some time was spent sitting in the lounge. On one occasion the television was turned on, but with the sound off, and music was playing on the stereo. Then the disc kept stopping and nobody seemed to know how to put it right, although one person did try. Eventually the music was turned off altogether, although the people sitting in the lounge were not asked if this was what they wanted. At the same time one person became increasingly agitated, thinking they were in the middle of a game of dominoes, and other people were becoming upset by this person’s behaviour. After almost an hour a member of staff went with the person to play dominoes in the dining room. There appeared to be plenty of staff available, but the situation escalated because staff did not seem to know what to do and did not handle it effectively at the beginning. A similar situation was witnessed during the second visit to the home. The home’s management needs to train the staff and explore ways of providing a wider range of activities that people will take part in and enjoy. There is no activities co-ordinator employed at Bronte Park. Everyone who commented said they enjoy their meals. There is a good variety of dishes on the menu and special diets are catered for. The cook and the rest of the staff are aware of people’s needs and preferences. Assistance is offered to people who are not able to eat independently. Before mealtimes, people are asked if they would like to choose from the menu; people were making alternative choices if they wished. One person’s daily record showed that their personal choice of food for breakfast was provided. Another person’s care plan showed that they had designed their own menu plan. This person confirmed that the plan is followed. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience poor 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 make a complaint if they are dissatisfied with the service. People are not protected as not all of the staff have received adult protection training or understand the procedures to follow if abuse is reported. EVIDENCE: The complaints procedure is clear and easily available. Concerns have recently been raised with us about the potential risks arising from the client mix in the home, inadequate staffing levels and lack of preadmission assessments. Staff mentioned their concerns that they, and other people, are being exposed to verbal abuse from one person who was recently admitted to the home. These concerns have been brought to the attention of the home’s management. Not all of the staff have had Adult Protection training. This needs to be arranged without further delay, to make sure the staff are fully aware of their role in protecting the people they support and care for. Since the beginning of September 2007, there have been two adult protection issues, both of which were reported to Social Services but not directly to the Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 16 adult protection team. Social Services’ staff have re-assessed the people’s care needs and taken appropriate action to minimise the risk and, where necessary, find more suitable care. Only one of these incidents was reported to us. In addition, regular incidents of challenging behaviour have been recorded in some people’s daily record notes, and on incident forms. Some of these incidents have posed a verbal or physical threat to people’s mental and physical well-being. These findings were referred to Bradford Social Services Adult Protection Team by us, and a strategy meeting has been held. At this meeting the home’s acting manager, registered providers and other health and social care professionals have reached an agreement about the best way for the home to meet the needs of everyone at Bronte Park. The relevant policies and procedures must be kept up to date, to guide staff. This includes a robust ‘whistle blowing’ policy and procedures to reassure staff that they will be protected if they ever had to report any suspicions of abuse or poor practice. People have access to independent advocacy services. There was evidence available to confirm that one person is making use of the service to help them through a difficult period. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 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. People live in a safe, comfortable and homely environment, although some areas require attention. EVIDENCE: There is a programme of re-decoration for the bedrooms, as well as for the rest of the house. During this year new carpets have been laid in the lounge and hallway. The bathroom on the first floor needs attention. The bath panels are broken and a hoist had been left there, restricting access to the wash hand basin. Also there was no soap at the basin for people to use. Generally the home is kept in a clean and hygienic condition. However, there was a noticeable odour when walking into the lounge directly from the front door and there was also an odour in one of the bedrooms. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 18 The grounds are tidy and people are able to go out and enjoy the fresh air and countryside, when the weather permits. One person confirmed how important it was to be able to get outside. Another person said they enjoyed watching the wildlife in the gardens and told me about the animals and birds that can be seen there. No progress has been made to the plans to create a second lounge area and some of the paintwork in the house is scuffed. To accommodate the changing needs of the people who now live at the home, an additional lounge would be a valuable facility. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 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. Staff are employed in sufficient numbers to meet the needs of people living at the home. People are protected by the staff recruitment procedures. Staff do not have the skills and knowledge they need to meet the needs of everyone living at the home. EVIDENCE: The staff rotas confirmed that, at the time of the first visit, there were enough staff on duty to meet the needs of the people living at the home. For example, on the Thursday afternoon there were three care assistants, one nurse and the Deputy Manager covering the shift, as well as the Acting Manager. While sitting in the lounge during the first visit there seemed to be plenty of staff available. However their lack of understanding about how to support someone whose distress was upsetting the individual concerned and other people, as described earlier in the report, and the shortage of stimulating activities suggests that staff are not fully aware of how to meet the needs of the people living at Bronte Park. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 20 On our second visit there were fewer staff on duty. In order to meet the high care and support needs of the people who live at the home, we left an Immediate Requirement Notice stating that the staffing levels must be increased to one qualified nurse and four care assistants between 8am and 8pm each day. Staff rotas have been provided to the Commission, confirming that there is now one nurse and four care assistants on duty during these hours. Staff need to have comprehensive training to help them understand and respond to the needs of the people they support. This should include training in subjects such as dementia care, challenging behaviour and providing suitable activities for everyone. Three staff files were looked at. They all included a completed application form and two written references had been obtained. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks had also been obtained. New staff do not begin work until these checks have been completed satisfactorily. The management must make sure the staff have up to date training in all the mandatory areas, including health and safety, moving and handling and adult protection. The acting manager has already arranged training in various areas including infection control, first aid and staff supervision. New care staff follow a twelve week accredited induction training programme followed by completion of a foundation training portfolio. This basic training makes sure staff have a good understanding of their role and responsibilities, and provides a sound basis for NVQ study. Many of the staff who work as care assistants are from overseas and have qualified as nurses in their own country. Staff who have no formal qualifications are supported and encouraged to take a National Vocational Qualification (NVQ) in care. Since the former manager left, the home only has one nurse with specialised mental health training and this person works on nights. The people who live at the home have a wide range of mental health support needs. They and the staff team would benefit from having more than one member of staff with specialist skills and training. The providers told us that they are advertising for qualified nurses with specialist skills in mental health. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not effectively managed to meet the specialist needs of the people living at the home. EVIDENCE: The registered manager has left and the Area Manager is currently managing the home. The Area Manager is not a nurse, but is supported by the Deputy Manager who is a registered nurse. A registered manager must now be recruited to the vacant post. After the last inspection we requested that the management provide us with an improvement plan to show how they were going to address the issues raised in the report. No improvement plan was provided. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 22 Before this inspection a self-assessment questionnaire was sent, for the manager to complete and return to us. This document has not been returned, although reminders have been sent. Completion of this document is a requirement of the inspection process. The home’s policies and procedures are a standard set and have not all been adapted, where needed, to reflect the individual circumstances of Bronte Park. This needs to be done to make sure they provide relevant information to guide staff on how to act in every situation. The home looks after small amounts of people’s money, to pay for their dayto-day expenses. The records and monies are stored safely. Most of the regular health and safety checks for the home are carried out in a timely manner. At the time of the inspection the stair lift annual check was overdue. The fire alarm tests were up to date. All these measures are essential to make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. It has been agreed that one person is allowed to smoke in their bedroom. The fire safety officer should be contacted for advice on this and a detailed risk assessment must be developed. The records showed that the fire alarm in this room is tested regularly. The home carries out a number of quality assurance measures to assess the quality of the service and gain information for service quality improvements. These include internal audits of medication and health and safety measures as well as sending out questionnaires to the people who live at the home, their relatives and health and social care professionals. The information gained is collated and followed up where needed. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 3 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 2 Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1)(a) Requirement To confirm that the home can meet individual’s needs, preadmission assessments must be completed for each new person. 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 timescale of 31/03/07 not met). For the safety of the people who live at the home the medicines records must be accurate and up to date. A range of activities must be provided to stimulate people with dementia, on a group and individual basis both in the home and outside. To provide a safe, wellmaintained environment, the maintenance works identified in this report must be completed. Dispensed soap and paper towels must be provided in all communal bathrooms and toilets DS0000050797.V354349.R01.S.doc Timescale for action 31/01/08 2. OP7 15(2)(c) 31/03/08 3. OP9 13(2) 31/01/08 4. OP12 16 (2)(m) & (n) 28/02/08 5. OP19 23 31/03/08 6. OP21 Reg 13 (3) 31/01/08 Bronte Park Version 5.2 Page 25 7. OP26 Reg 16 (2)(k) 18(1)(c) 8. OP30 9. OP31 8(1)(a)(b) 10. OP38 23(2)(c) 11. OP38 13(4) 12. OP31 37 13. OP27 18 to prevent the spread of infection. The home must be kept free from offensive odours so that people live in a pleasant environment. To make sure staff have the skills and knowledge necessary to support people, all staff need to complete the mandatory health and safety training, and other relevant courses such as dementia care training. A suitable manager must be appointed and registered with the Commission for Social Care Inspection, to make sure that the home is run and managed well. For the safety of the people who live at the home and the staff, all safety checks to the home’s equipment, such as the stair lift, must be completed within their due time. 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 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 when a significant incident occurs. Suitably experienced and qualified nurses with mental health experience must be employed to work in the home to make sure that people’s specialist needs are met. 31/01/08 31/03/08 28/02/08 28/02/08 28/02/08 31/01/08 28/02/08 Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 26 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 OP22 OP38 Good Practice Recommendations Equipment should not be stored in the bathrooms where it restricts access to the facilities. The home’s policies and procedures should be updated to reflect the needs of the current service and guide staff. Bronte Park DS0000050797.V354349.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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.V354349.R01.S.doc Version 5.2 Page 28 - 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. 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