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Inspection on 09/01/07 for Brownscombe House Nursing And Residential Home

Also see our care home review for Brownscombe House Nursing And Residential Home for more information

This inspection was carried out on 9th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff on duty on the day of the site visit were helpful and friendly and the inspector noticed good interaction between them and the service users especially during lunchtime. Service users told the inspector that the staff were kind to them. Service users also told the inspector that they enjoyed the food and that they were always given a choice. The inspector sampled some compliment and thank you cards that the home had received and positive comments were made about the staff and treatment service users had received. The nurse in charge was clear about her role and responsibilities and showed good knowledge of the service and their policies and procedures.

What has improved since the last inspection?

A programme of refurbishment has taken place since the last visit. Some bedrooms have been decorated and furniture replaced. New carpets have been laid in the communal areas and also some bedrooms.

What the care home could do better:

Observations made during the visit and feedback from the nurse in charge, staff and comment cards received evidenced that the staffing numbers were not sufficient to meet the service users needs. The home needs to address the staffing arrangements and recruit staff in key areas for example a chef and maintenance person. On the day of the site visit staff said they are always rushed and have difficulty finishing tasks. It was requested that the general manager review the staff numbers to ensure that there are sufficient staff on duty to meet the service users needs. The home should consult with the local environmental health department regarding smoking near the kitchen area and for the safe storage of food in the refrigerators. Hot water must be maintained at a safe temperature. Thermostatic valves should be in place where required and the temperatures checked on a regular basis. The corridors should be free from clutter to ensure the health and safety of all service users.

CARE HOMES FOR OLDER PEOPLE Brownscombe House Nursing And Residential Home Hindhead Road Haslemere Surrey GU27 3PL Lead Inspector Lesley Garrett Unannounced Inspection 9th January 2007 09:30 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 Brownscombe House Nursing And Residential Home DS0000017596.V325436.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. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brownscombe House Nursing And Residential Home Hindhead Road Haslemere Surrey GU27 3PL Address 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) 01428 643528 Mr L Hasham Mrs Elizabeth Jane McAllister Care Home 36 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (36), of places Sensory Impairment over 65 years of age (1) Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 25 beds may be used for the provision of nursing care for elderly people from the age of 60 years One (1) named service user within the category SI/E (Sensory Impairment - over 65 years of age) may be accommodated. 14th October 2005 Date of last inspection Brief Description of the Service: Brownscombe House is a care home providing nursing care for 36 residents with old age. The home is owned and run by Care Homes of Distinction who also run similar establishments in Surrey. Brownscombe House is a large building in Haslemere that provides accommodation over three floors, which can be accessed by a lift. There is parking available to the front of the house. The weekly fees are between £442 - £725 Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of a key inspection and took place over eight hours commencing at 0930 and finishing at 1730. Mrs L Garrett regulation inspector completed the visit. The registered manager was not available on the day but the inspector has had the opportunity to speak with her following the visit. The nurse in charge on the day assisted with the visit and was joined at midday by the general manager for the service. A tour of the premises took place and the inspector spoke to some service users and staff. A pre-inspection questionnaire has been sent to the service and will assist with this report and ‘comment cards’ from service users and their relatives had also been returned to the Commission for providing feedback regarding the service. Records were sampled as part of the inspection process including care plans and policies and procedures. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this site visit. What the service does well: What has improved since the last inspection? Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 6 A programme of refurbishment has taken place since the last visit. Some bedrooms have been decorated and furniture replaced. New carpets have been laid in the communal areas and also some bedrooms. What they could do better: 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. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admission assessment that is undertaken ensures that service users can be confident that their assessed health care needs will be met. The home has one intermediate care bed and service users are helped to maximise their independence in order to return home. EVIDENCE: The nurse in charge advised that the manager completes all the pre-admission assessments prior to service users moving into the home. The nurse in charge told the inspector that if the registered manager was away or not available then she would do the assessment herself. A standard document is used by the home to do the assessment, which takes into account the activities of daily living, which includes mobility, skin integrity and nutritional needs. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 9 The pre-admission information of a newly admitted service user was seen and this provided sufficient information to ensure that the staff in the home would meet their health care needs. During the previous inspection in October 2005 the inspector noted that the procedures for admission for intermediate care were not adequate. The manager has written procedures for this bed, and the nurse in charge told the inspector that these are adhered to by the registered nurses and they now meet the needs of the service users and meet the outcomes. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual plans, which reflect the care, and support they require and their health care needs are fully met. Medication policies and procedures are in place that is used appropriately by staff to protect the service users. The privacy and dignity of the service users is respected. EVIDENCE: Three care plans were sampled during the site visit and there was evidence that the staff reviewed and updated these plans every month. Service users and relatives are encouraged to participate in the process and there was evidence of their signatures. The inspector saw evidence of risk assessments in particular nutritional and those that identified service users who could be at risk from developing pressure sores. Bed rail assessments were also in place. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 11 There was no evidence at the site visit that service users had made choices about their preferences for socialising or any personal history that they had discussed. The inspector had a conversation with the registered manager following the site visit who stated that she was in the process of developing these documents and they would soon be in place. She had also sought advice from the National Association for Providers of Activities (NAPA) for ideas for compiling this document. The home has the support of a local General Practitioner (G.P.) who visits every two weeks and as required. The nurse in charge said that the home also has opticians that visit twice a year and a chiropodist that visits every six weeks. The nurse in charge stated that it has been very difficult to secure the services of a local dentist therefore the service users usually kept their own dentist and visits are organised as necessary. Medication stores and records were seen. The inspector observed no omissions on the medication administration charts that were sampled. The home is supplied with medication from a local chemist and blister packs are used. Some of the controlled drugs were sampled and found to be correct. All personal care is delivered in service users own rooms. Staff were observed to be knocking on the doors prior to entering and several service users told the inspector that the staff were kind to them. The preferred name of each service user is used and staff can access this information in the care plan where it is highlighted. The home has a privacy and dignity policy and the nurse in charge stated that this subject is also discussed during induction for all new staff. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities take part in the home, which are provided by the staff and visiting activity providers. Contact with family and friends is maintained and service users are able to exercise choice and control over their lives. Wholesome and nutritious food was served on the day of the site visit. EVIDENCE: It was reported to the inspector that the home has had no activities organiser for four months so staff and outside providers have been providing the social stimulation for service users. The nurse in charge said that staff have organised quizzes and board games and will sit and talk with service users and provide one to one interaction. The nurse in charge stated that the service users had enjoyed the dancing on the television on Saturday nights before Christmas and they all sat in the lounge to watch together. Outside entertainers visit every week for musical sessions and an exercise class takes place every week also. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 13 Communion services are held every month and the nurse in charge told the inspector that other religious denominations could be catered for when necessary. The general manager and nurse in charge said that the activities organiser from another home within the group is about to visit the home for two to three days a week and will visit next week to start the social assessments so that an activity programme can be started. The inspector spoke with the manager who stated that The National Association for Providers of Activities (NAPA) has provided some training in the home for the staff, which has been both enjoyable and useful. Family and friends are welcomed to the home and the nurse in charge said there is no restrictions to the visiting time. It was also stated that all visitors to the home could see their relative or friend in private if requested. Service users that the inspector met during lunch told her that they had been given a choice of food that morning for lunch. They had also made choices about where they would like to eat their meal. During a tour of the home it was observed that rooms had been personalised. The nurse in charge said that no service user handles their own money. The home’s cook left last year and has not been replaced yet therefore the kitchen is staffed with agency staff and the help of some of the homes staff on occasions. The cook told the inspector that they have a four-week menu cycle and that each service user is given a choice during the morning for their lunch. The inspector observed the lunch time meal and found that the service users had access to adapted cutlery for those that needed this facility. The service users told the inspector that they enjoyed the food and on the day there was a good variety of fresh vegetables available. Specialised diets are also available and the inspector observed a pureed meal, which looked appetising and colourful, and one service user who was a diabetic had a fresh fruit salad prepared for dessert, which she was enjoying. Fluids were available during lunch, which included squash and fresh fruit juice. The inspector also observed that fresh fruit was available and the nurse in charge stated that this is always available during the day not just at meal times. The inspector visited the kitchen and found that food stored in the refrigerator was not labelled giving no indication when the packet was open or the cooked food prepared. Staff was observed to be sitting by the open kitchen door smoking. It is a requirement that the home consults with the environmental health for the area in which the care home is situated to check the latest guidance on this matter. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can be sure that any complaint will be taken seriously and acted upon. Service users are protected from abuse as staff had clear knowledge of the procedures for safeguarding their welfare. EVIDENCE: During this site visit the inspector saw, clearly displayed, the home’s complaint policy and this contained clear timescales for action. ‘Comment cards’ received by the Commission prior to the site visit indicated that most of the respondents knew about the policy. The home has a complaints log but this was not available on the day of the site visit. The inspector spoke with the manager later who told her that any complaints received since the last inspection had now been resolved within the timescales. The home has a safeguarding adult’s policy and this is in line with the local authorities procedures. The inspector spoke with a number of staff that had good knowledge of what they would do if they witnessed abuse. The staff said they had training in abuse awareness and the inspector saw evidence of this in the training files. The general manager stated this training was ongoing. Since Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 15 the last inspection the home has had one incident referred under the local authority’s safeguarding adult’s procedures, which has now been resolved. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is maintained, decorated and furnished to a reasonable standard and in general the facilities are safe and clean. EVIDENCE: The layout of the home is over three floors. The lower ground floor, the ground floor and a mezzanine level with a number of small corridors. The home has no maintenance person and someone from another home comes once a week to do any mandatory health and safety testing. Carpets have been replaced in the communal areas and some of the bedrooms since the last site visit and some bedroom furniture has been replaced. The inspector saw a number of beds that were suitable for service users who were more dependent as they were able to be height adjusted, which benefits the service users that are increasingly frail. The general manager was made Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 17 aware of the malodour in the small lounge. The housekeeper had told the inspector that during the visit by the maintenance person carpets are often cleaned. The inspector observed the laundry facilities, which is a very small room, housed on the lower ground floor. The floor and walls are not impermeable and wall finishes cannot be readily cleaned. The housekeeper said that all laundry is carried out in this facility. There is one washing machine that has a sluice facility and a tumble drier. The general manager said that laundry is collected by a driver regularly and taken to a commercial laundry owned by the company and is delivered back. The inspector spoke to the manager following the inspection who said the driver comes four times a week but not on his days off or holiday periods. She said you had to watch for him or he would be missed. A requirement will be made for the home to address the laundry facilities as there is a concern that in such a small room, where dirty and clean laundry are in close contact and the room is unable to be cleaned adequately, an infection control issue could arise. The housekeeper said that the ironing is done by the night staff in the lower ground corridor. While overall the general environment of the home was good some practices in place did not promote the safety of service users and these are all detailed in the outcome area for management and health and safety. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff and the skill mix was not adequate to meet service users assessed needs and national vocational training needs to continue to ensure service users are in safe hands at all times. Recruitment records were not accessible, however discussions with the general manager indicated that appropriate practices were in place to protect service users. Staff receive training regularly and are competent to do their job. EVIDENCE: Prior to the site visit ‘comment cards’ had been returned to the Commission from service users and relatives and many stated that they felt there was inadequate staff numbers. The inspector spoke to the manager prior to the visit to ask for updated copies of the staff rota and dependency levels for the service users. The manager stated at that time that a previous decision to reduce staffing numbers was as a result of vacancies and a reduced number of service users. The inspector spoke with staff members on the day of the visit that stated that service users are still being washed up until lunchtime and that they were always very busy. The inspector saw a list in the nurses office that detailed six Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 19 service users that the night staff had to get up washed and dressed to help the day staff. The nurse in charge did say these service users were the ones awake and requesting to get up but this was only documented on the list on the wall and not reflected in the care plans. The inspector also spoke to the nurse in charge who does not have supernumerary hours and is called upon for a variety of tasks during the day and she is therefore often unable to assist the carers with personal care. The layout of the building over three floors, the ‘comment cards’ received and conversations with the staff team means that the staff numbers need to be reviewed and the numbers increased to ensure there is sufficient staff to meet the needs and dependency levels of service users. Staff have other tasks to perform as the kitchen is run by agency staff until a cook can be recruited and staff have helped in that department, they have also helped with activities and the night staff do the ironing. National Vocational Qualification (NVQ) training takes place but the home has a large number of their work force that are registered nurses in their own country and the general manager stated that they are equivalent to level 3 NVQ. The nurse in charge said that only one other member of staff has the level 2 qualification. Due to the absence of the manager on the day of the site visit recruitment folders were not accessible, as they had been locked away. The inspector had knowledge of the recruitment policy of the home as an inspection by her had taken place at another of the homes run by the same company. The same administrator is responsible for the recruitment. The inspector spoke with the general manger that confirmed the same recruitment practices took place. It is a requirement that records are available at all times. The home is supported by a training co-ordinator who is employed by the group to provide the training required. Mandatory training has taken place including manual handling, fire and safeguarding adults. Induction is also available and foundation training is linked to skills for care. The general manager stated they were going to liaise with the training co-ordinator to ensure that any staff handling food has a current food hygiene certificate. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by a manager that is fit to be in charge and is run in the best interests of the service users. Service user’s financial interests are safeguarded. Health and safety arrangements in the home must be improved to ensure service users are protected. EVIDENCE: The manager was not available on the day of the site visit but the inspector had met with her before and has had the opportunity to speak on the telephone following this site visit to clarify a couple of issues. The manager has been in post since 2001 and the general manager stated she has still to complete her registered managers award. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 21 The nurse in charge said that questionnaires are sent out yearly to service users to actively seek feedback about the service provided. It is recommended that the results of these surveys be fed back to the service users in a style that suits the home and that the views of other stakeholders are sought. The nurse in charge said that some service users keep small amounts of money with the home for safekeeping. This account could not be checked, as the manager was unavailable. The general manger said that all receipts are kept so an audit trail can be carried out. It is a requirement that all records are made available to the Commission for sampling. The inspector had the benefit of a pre-inspection questionnaire to check some of the health and safety checks that had been carried out. The home would benefit from a nominated person who could be at the home a little more frequently than once a week to carry out all the checks that are necessary. The general manager was unsure if all wash hand basins had thermostatic valves in order to ensure that hot water is provided at a safe temperature. It is a requirement for staff to check and monitor the temperatures of the hot water and valves must fitted where necessary to ensure all risks to service users are eliminated as much as possible. The inspector observed a corridor that was used for storing mattresses and there was also rubbish left against the wall causing a potential safety and fire hazard. The general manager said that she would organise this to be removed. A ladder was left in the corridor leading to a loft space where the nurse in charge said there had been a leak the previous day, again presenting a potential hazard to individual’s safety. The general manager stated this would also be removed. On the mezzanine floor the inspector found an unlocked linen room, which had cleaning fluids stored there but these were removed by the general manager at the time therefore no requirement was made. The room housing the boiler was found to be unlocked but the general manager also rectified this problem therefore no requirement made. Also on this floor the lift, when not in use, came to rest with the doors open. The inspector asked the general manager to consult with their lift engineer for the current legislation to ensure the health and safety of service users and staff. The downstairs sluice is in need of refurbishment and to stop the practice of placing pillows in plastic bags on the floor that need to be cleaned, as this too is an infection control issue. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 22 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 2 Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 23(5) Requirement Timescale for action 09/02/07 2. OP19 23(2)(l) 3. OP26 13(3) 4. OP27 18(1)(a) The registered persons must undertake appropriate consultation with the authority responsible for environmental health regarding storage and labelling of food and smoking at the kitchen door. The registered persons must 09/02/07 ensure that suitable provision is made for storage so that the corridors remain free from hazards to service users and staff safety. The registered persons must 09/02/07 ensure that suitable arrangements are in place to prevent toxic conditions and the spread of infection at the care home. The registered persons must 09/02/07 ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. A review must take place of the current staffing levels with a view to increasing the numbers DS0000017596.V325436.R01.S.doc Version 5.2 Brownscombe House Nursing And Residential Home Page 24 5. OP29 OP35 17(3)(b) 6. OP38 13(4)(c) 7. OP38 13(4)(a) to ensure the needs and dependency levels of service users are met. The registered persons must 09/02/07 ensure that at all times records are available in the care home for inspection by any person authorised by the Commission to enter and inspect the care home. The registered persons must 09/02/07 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Water must be maintained at a safe temperature and it must be established if thermostatic controls are fitted to wash basins where these are required. The registered persons must 09/02/07 ensure that all parts of the home to which service users have access are so far as reasonably practicable are free from hazards to their safety. Consultation must take place with an appropriately qualified engineer regarding the use of the lift and for current legislation for lift doors. 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 OP33 Good Practice Recommendations It is recommended that the results of service user surveys are feedback to them and that other stakeholder’s views are sought. Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Brownscombe House Nursing And Residential Home DS0000017596.V325436.R01.S.doc Version 5.2 Page 26 - 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. 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