Inspection on 27/09/05 for Broomhill

This inspection was carried out on 27th September 2005.

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

Broomhill 24/04/08

Broomhill 19/07/07

Broomhill 25/01/07

Broomhill 16/02/06

Broomhill 11/03/05

Broomhill 15/11/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Broomhill 92 Eastwood Road Brislington Bristol BS4 4RS Lead Inspector Sandra Garrett Announced 27 and 28 September 2005 09:30 th th 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 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. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broomhill Address 92 Eastwood Road,Broomhill, Bristol,BS4 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9779802 0117 9724091 Bristol City Council Mrs Penny Fry CRH-PC Care Home only 40 Category(ies) of OP (Old Age) (40) registration, with number of places Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The Home may accommodate two named individuals with mental health needs who are under the age of 65 years. The registration will revert when these persons leave the home Date of last inspection 11 March 2005 Brief Description of the Service: Broomhill operated by Bristol City Council and is a 40 bedded home situated in the residential area of Brislington. The nearest shops are 300 yards away where there is a post office, newsagents, hairdresser, pub and supermarket. The home is on 3 levels with 2 lifts providing access to all areas of the building. There are 4 lounges around the home and a large spacious dining room on the 1st floor. All bedrooms are single and contain a wash hand basin. Toilets and bathrooms are close by. The garden is accessible with rails to assist the service users onto the patio area. The area has a new rockery with a water feature. A first floor balcony offers residents the opportunity to sit and look at views across to Bath and surrounding countryside. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection generally focussed on the care of older people, some of whom have dementia or mental health impairments. Ten of thirty four residents living in the home at the time of the visit were spoken to. One resident said ‘I couldn’t wish for a better home’ and all those spoken to were appreciative of staff and the quality of the meals provided. A wide range of documents was examined including the pre-inspection questionnaire, care records, complaints, accident and health and safety records. What the service does well: What has improved since the last inspection? From the eight requirements made at the last inspection in March this year, all except one part of a requirement were met. The requirements met included: Care plans now record residents’ preferred names and are reviewed monthly. Any changes are recorded and updated to ensure residents’ needs continue to be met. All bathroom radiators have been covered to protect residents from risk of harm. Photographs of each staff member are now included in staff profiles to ensure residents are protected from risk. Training in caring for older people with mental health problems has been provided and continues to be updated so that staff are better able to care for residents with mental health impairments. Risk assessments particularly in respect of falls and the environment have been put in place to protect residents from risk. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 6 Further, four requirements and a good practice recommendation made at an additional visit to the home on 18 July ’05 were also met. These requirements were in respect of a person who had been admitted to the home on a temporary basis following a crisis at home. Three requirements and a recommendation were made were in respect of meeting her/his needs. One was made in respect of the lift that needed a risk assessment and clear warning of potential hazard to frail older people using it. What they could do better: Part of a requirement from the last inspection was not met. This was in respect of notifying the Commission for Social Care Inspection of any event that adversely affects residents, including death, serious illness or injury, misconduct of staff and environmental issues. Two new requirements were made in respect of staffing matters. These were: Proof of identity for each staff member must be kept at the home to ensure residents are fully protected. Supervision must be given to each member of staff at a minimum of at least 6 times yearly to ensure that trained and regularly supervised staff care for residents. Two good practice recommendations were made. These were that: • The home should take action to ensure that each resident is given a weekly personal allowance that is paid to them regularly, so that they are able to have some financial independence and choice. Activities records should reflect residents’ enjoyment of activities, entertainments and outings so that it is clear that residents quality of social life is maintained within the home. • 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. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 Attention needs to be given to improving the information given to residents in respect of admission procedures to ensure the home can meet potential residents’ needs at the point of entering the home. Procedures for ensuring the home can meet potential residents’ needs are satisfactory. EVIDENCE: It was disappointing to note that a requirement from a previous inspection that was followed up at the last visit, had not been met. This was in respect of updating the Statement of Purpose and Service User Guide to include the address details of the Commission for Social Care Inspection so that residents would be able to contact the Commission if they wished. It was agreed with the manager that this would be done immediately and a copy sent to the Commission. A good practice recommendation had been made at the previous inspection in respect of finding ways to assess people before they are admitted into the home. The manager said that assessment visits are carried out if the resident is to be admitted from hospital, as staff can get a clear picture of how their assessed needs are to be met. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 9 Assessing staff (usually the manager or an assistant manager) find it very useful to assess potential residents in this way. However the manager said that it’s more difficult to assess potential residents in their home setting. This is because the picture may be unclear due to their circumstances. A thorough assessment during the four-week trial period is found to be more useful in assessing whether the home can fully meet someone’s needs. From care records examined, social services care assessments were seen together with reviews done by the social worker after the month’s trial period. The care plans developed by the home followed the social work one and both the manager and resident had signed the review to say that the home could meet the resident’s needs. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 Care plans need attention to ensure that they reflect the changing needs of residents and the home’s ability to meet assessed needs. Residents’ are well looked after in respect of their health and medication. EVIDENCE: Three residents’ care files were examined at this visit. A requirement made at the last inspection was found to be partly met. This included requirement to record each resident’s preferred name, monthly reviews to be carried out and recorded and amendments to be made that reflect changes following review. Photographs of each resident were seen in files together with the name they wish to be called. Clear information in respect of monthly reviews were seen and amendments/updates written on the care plan. Residents had signed their care plans and had been given opportunity to comment on them. Care plans were comprehensive and covered a wide range of assessed needs to be met. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 11 However for two residents whose needs had recently changed, their care plans had not been updated to reflect the changes nor had actions or outcomes been recorded. Manual handling risk assessments had also not been updated to reflect the changes, nor had a specific risk assessment in respect of falls been done. One resident now needs nursing care and a letter from a psychogeriatrician was seen that confirmed this. The manager said that a nursing home placement is being found for this resident. It was pleasing to note after discussion that a new updated care plan and risk assessment in respect of falls had been done by the second day of inspection. For the other resident who had transferred from another home, no new care plan had been put in place although the existing one done by the previous home had been updated in pen. The manager said that a new plan was to have been done at the end of the four-week trial period. However this had not been done and the resident’s assessed needs had significantly changed. It was pleasing to note that a new, more holistic and detailed care plan was sent to the Commission’s office within one week of inspection. Details of healthcare needs being met were seen in all care records and in the home’s communication book. This recorded visits by opticians, chiropodists, GPs, community psychiatric and district nurses. Healthcare professionals were seen visiting residents at the home during the inspection. Appropriate healthcare equipment had been purchased to assist with caring for residents and records were seen in respect of this. A medical room was seen on the first floor that contained a metal locked cabinet for medications and a locked fridge to keep medications requiring storage at low temperatures. A minimum/maximum thermometer was seen together with a book of recordings done daily. Average temperatures were within recommended guidance. Details of new prescriptions e.g. for antibiotic therapy were recorded in care files. The medications practice was observed at lunchtime and carried out appropriately. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 Attention needs to be given to ensuring residents’ enjoyment of activities is recorded to demonstrate that activities are of their choice and meet their needs. Contact with the local community ensures residents are not isolated or excluded. Residents meals provide them with a good standard and choice. EVIDENCE: Details of regular activities, entertainment and outings were seen on notice boards and in specific records kept by staff. These included: DVD or video showings, singalongs, arts and crafts, games and music tapes and CDs. From the residents meeting minutes of 13 September ’05, outings and Christmas arrangements were discussed. A trip to Bristol Zoo had taken place on two separate days in September. It was noted that residents were able to say what they wanted to happen and what they didn’t want. Individual residents were able to request activities or outings that they wanted to do and it was noted that key workers take residents out e.g. shopping or to the local pub for meals. This happened during the inspection. However it was also noted that one resident had expressed a wish for a yoga class that had not been arranged. The resident had been offered a yoga video instead. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 13 From the quality assurance report dated May ’05 it was noted that activities scored lower levels of satisfaction than other areas. Residents spoken to had mixed feelings about activities, some saying that there were not enough. The report also stated that residents would like more organised activities. Records of activities, entertainment and outings showed the quantity of both the activity and the number of residents attending, yet had no qualitative information about how residents enjoyed the particular session. From all the above it wasn’t clear whether all residents are fully satisfied with what’s on offer or provided, although it was clear that staff work hard to make sure residents are able to have a choice of activities, entertainment or outings. The home has a cat ‘Tabs’ who is well looked after and liked by residents. A risk assessment is in place that details risks associated with keeping a pet cat. The home has good links with the local community. These include regular contact with the local pub where residents go for meals in small or large groups. The pub also hosts events for residents. The local neighbourhood watch meetings are held at the home that some residents attend. Students from the local school visit the home at Christmas and Easter, and bring gifts for residents. Residents praised the food and meals at the home and lunch was taken with them on the first day of inspection. Two choices of meal were available either lamb chops or meat pie, with a selection of vegetables. There was a wide choice of dessert and the meal was tasty, wholesome and nutritious. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Complaints are well managed although attention is needed to ensure all complaints are appropriately recorded. This is to ensure that residents can be confident their concerns will be taken seriously and that they are protected from risk of abuse or harm. EVIDENCE: The complaints record was examined and found to be in order. Complaints recorded showed evidence of clear investigation and outcomes were reported back to the complainant within 28 days. However a complaint was noted in the home’s internal communication book that gave no indication of how it was investigated, the outcome for the person who had complained and the timescale within which it was resolved. The manager gave information about the issue that was about a situation in the bar that could have put residents at risk. All staff have done training in Adult Protection issues. The manager said that incidences of alleged abuse had been referred appropriately for further action. A requirement made at the last inspection in respect of this was met, although it was noted that the home had had no feedback following referral of adult protection matters that would have led to protection plan meetings being held. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,24 &26 Accommodation provided for residents is of good standard and comfort. Attention is further needed to protect residents from hazard while bathing. EVIDENCE: The home is laid out on three floors with the office and some bedrooms at ground level, dining room, lounges and access to the garden on the first floor and more lounge space and bedrooms on the top. The home has a lift although it was noted that there had been problems with it levelling out when it stopped at each floor. A requirement under Standard 38 had been made at the additional visit in July. Residents had now been made aware of the risk by means of hazard tape across the entrance to it and the lift engineers had visited regularly to ensure it met safety requirements. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 16 There are appropriate numbers of toilets and bathrooms on each floor of the home and several of these are accessible to older disabled people. Toilets and bathrooms were clean and hygienic at this visit. A requirement made at the last inspection for all bathroom radiators to be covered, was met. However one bathroom on the top floor of the home has a stainless steel free-standing heated towel rail that could prove hazardous if a resident fell against it. This must be risk assessed and replaced by a low surface temperature radiator if necessary. Residents’ bedrooms were seen to be of different sizes. Rooms were furnished appropriately and lots of them included residents’ personal possessions. One resident said s/he would like another chair in the room for when visitors call. However on visiting the room, it was noted that the resident had lots of furniture and personal effects that left little room for an extra chair. The manager said the resident would be offered a larger room when one became available. The home smelled fresh and was clean and hygienic at this visit. A domestic staff member was seen using a new carpet cleaning device that she said is in constant use and improves the quality of carpet cleaning. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Staffing levels are well managed that ensures residents’ personal care and social needs are met. A good programme of and attendance at training courses enables residents to be confident of the care they get from staff. Improvement is needed in obtaining personnel records to ensure residents are fully protected. EVIDENCE: The manager said she monitors staffing levels needed against the dependency levels of residents and used a ‘care time indicator ‘ sheet to calculate how many care hours are needed per resident. At this visit appropriate numbers of care staff (four in the morning and three in the afternoon) were on duty to offer personal care and to do more social activities with some residents e.g. going to the pub for lunch. From the pre-inspection questionnaire rotas were seen that demonstrated how care hours are covered and highlighted cover needed. Agency staff are used although as far as possible the same staff are booked to work at the home each time. Residents spoken to however said that the home was ‘sometimes short staffed’ although they went on to say they feel the staff meet their needs. Progress towards staff gaining NVQ at some level was noted. Four staff already have NVQ level 2, three are working towards getting it and two more have started this year. Two domestic staff have NVQ level 1. The deputy manager is doing NVQ level 4. This is good practice. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 18 A requirement made at the last visit in respect of photographs of each staff member being done to keep in staff files, was met. However on examining staff files more fully, no proof of identity for any staff member was seen. Further some staff expressed their concerns on the need to keep what they consider to be personal and confidential information on file. It was explained to them that the requirement is for residents’ protection and the manager was advised to discuss this further at a staff meeting. A new requirement in respect of this issue is therefore made. It was pleasing to note that a requirement in respect of training in working with people with mental health needs and behaviours that challenge was also met. Information was seen about a four day course that many staff had attended and others were completing. It was noted that six staff had attended this training in March this year and a further nine had attended another day in April. Feedback from the course was good. Staff training records showed information about forthcoming courses. These included: Adult Protection, communication and support for people with dementia and effective recording skills. The manager confirmed that all staff had done Adult Protection training and some staff were having further updates. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 36, 37 & 38 Residents benefit from experienced management and their views are sought in respect of the care they receive. Attention is needed to ensure all residents are able to have enough money to spend. Supervision of staff must be improved in order to protect residents from risk of harm. Records including health and safety, are well maintained that ensures residents and staff are protected. EVIDENCE: The manager is experienced and has been at Broomhill for a number of years. She was welcoming and open to the inspection process. It was pleasing to note that she followed up requirements and recommendations promptly. It was noted that the manager operates an ‘open door’ policy and residents were met when they came to the office to discuss issues with her. The manager operates the home from a person-centred position that enables her to understand and help to meet resident’ needs. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 20 It was noted that a Quality Assurance survey had been carried out at the home in May ’05. A firm of independent consultants had carried out the survey and a copy of their report and findings was given to the inspector at this visit. The report findings corresponded with those found at this visit particularly in respect of environment, food and drink and staffing, all of which scored highly. The manager said she has no formal development plan to address issues that came out of the report although discusses findings in residents meetings. A copy of the latest residents meeting was seen that confirmed issues such as a greater choice of activities and outings raised in the report were discussed. A check of residents cash was carried out and a sample of monies held was checked. It was disappointing to note that some residents lacked any money at all or had very little to spend. The manager said this had caused some difficulties and was discussed with individual families or representatives at care reviews. A good practice recommendation is made to ensure the home continues to work on residents’ behalf to ensure they have their personal allowances paid to them regularly. A number of supervision records were checked to ensure supervision is carried out at least six times yearly. It was disappointing to note that there were lots of gaps in supervision records and further the records themselves were disorderly making it hard to know when supervisions had taken place. It became clear that supervision was taking place infrequently for some care staff. A new requirement is therefore made in respect of this. Daily records written for each resident were examined. These confirmed actions in respect of meeting personal care needs and were largely respectful and person-centred. However it was noted that a number of times the word ‘refused’ was seen when a resident had expressed that they chose not to do something. In the inspector’s opinion this word can be interpreted negatively i.e. the resident refusing to comply with an instruction or request, and should be avoided. Health and safety records were looked at that showed evidence of regular checks in respect of water temperatures and fire safety. Contractors visits were logged and copies of their findings kept in the files. The last fire drill was carried out in July ’05 and used as training practice. Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 2 x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x 3 3 x 2 2 3 2 Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 22 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 OP16 Regulation 22(2)(3) Requirement All complaints must be recorded in an appropriate way and in the relevant file so that residents or their relatives can be confident of investigation and outcomes within the timescale set The heated towel rail in the top floor bathroom must be replaced with a low surface radiator to protect residents from harm Proof of identity of each staff member must be obtained and kept in the home Supervision of each staff member must be carried out at a minimum of six times yearly Notices must be sent to the Commission for Social Care Inspection in respect of any event adversely affecting residents and including death,misconduct of staff, environmental issues and serious illness or injury (timescale not met from the 11 March 05 inspection) Timescale for action 1 November 05 2. OP21 13(4)(c) 1 November 05 30 November 05 31 December 05 30 November 05 3. OP29 4. 5. OP36 OP38 19(1)(b)(i ), Schedule 2 18 (2) 37 (a) to (g) Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 23 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 OP12 OP35 Good Practice Recommendations Activities records should demonstrate residents enjoyment of activities, entertainment and outings provided for their benefit. Action should be taken to ensure that each resident is able to have their weekly personal allowance paid to them without difficulty Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury Bristol BS32 4RG National Enquiry Line: 0845 015 0120 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 Broomhill D56_D05_S35843_Broomhill_V242998_270905_Stage4.doc Version 1.40 Page 25 - 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!