Inspection on 27/09/05 for Brymore House

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 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

Brymore House 27/02/07

Brymore House 06/02/06

Brymore House 31/03/05

Brymore House 28/10/04

Brymore House 14/01/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Brymore House Brymore House Residential And Nursing Home 243 Baring Road Lee London SE12 0BE Lead Inspector Ornella Cavuoto Unannounced Inspection 27th September 2005 10:00 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 Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brymore House Address Brymore House Residential And Nursing Home 243 Baring Road Lee London SE12 0BE 020 8851 4592 020 8851 4207 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) Mr Michael Marjoram Mrs Mary Marjoram Mrs Sharon Feleppa Care Home 46 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0), of places Terminally ill (0) Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. to include one person with palliative care needs 30 patients elderly, frail persons aged 60 years and above (female) and 65 years and above (male) 20 residents persons aged 55 years and above, and persons suffering from dementia 14 of the beds registered as `nursing` can be used for either patients or residents - maximum of 46 patients and residents combined up to 5 patients, aged 60 or above if female or 65 and above if male, for intermediate care using bedrooms 3-7 providing that the intention to create an additional, dedicated lounge/seating area is completed by December 2005 31st March 2005 Date of last inspection Brief Description of the Service: Brymore House is located on a main residential road and is about 5 minutes walk from Grove Park railway station and the local shops. The house is a large detached property with its own drive. There is an attractive enclosed garden and patio at the rear of the house. The accommodation is on three floors with a shaft lift providing level access to all parts of the home. The registration is for a maximum of 45 service users, up to 30 of whom may require nursing care. There is also one place for palliative care and up to five places for intermediate care. There is currently building works going on to complete a dedicated space for the intermediate care, which should be completed by December 2005. The manager is a Registered General Nurse and has considerable years of experience. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced visit carried out over one day and lasted a total of 12 hours. The inspection included speaking to nine service users, seven staff members including nurses and care staff. The registered manager was on annual leave on the day of the inspection although was present for a brief period during the inspection giving an opportunity for some discussion to take place. However, the deputy manager was spoken to and was present for the majority of the duration of the inspection. Other inspection methods used included a tour of the premises and inspection of records. What the service does well: What has improved since the last inspection? What they could do better: Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 6 The service needs to address the social care needs of individual service users more effectively by ensuring these are assessed as part of the care planning process. In respect to the improvements that have been made by the introduction of an activities co-ordinator, these need to be consolidated and expanded. Feedback needs to be obtained from service users about activities arranged in order to facilitate the development of a programme that relates more to their personal preferences and leisure interests. Care plans are in place for all service users but these are not signed to evidence that service users or relatives, where it is appropriate are involved in the drawing up of individuals’ care plans. Service user’s ability to self administer medication needs to be looked at as part of the service user plan and risk assessment to ensure that those that can administer their own medication are encouraged to do so in order to maintain their independence. Service users spoken to were unaware of the home’s complaints policy or that if they have concerns they are able to contact the Commission for Social Care Inspection directly. The complaints policy needs to be accessible to service users and it is essential service users are made aware of their right to complain and that complaints will be responded to fairly and swiftly. Staff must be given regular supervision and training needs addressed and this should be recorded on individual staff files. Staff spoken to had not all been in receipt of adult protection training nor were they aware of the home’s policy on adult protection. This requires attention to ensure that services users welfare and safety is upheld. Quality assurance needs to be improved and consideration be given to the introduction of an independent quality assurance system. Although, the home has completed a questionnaire to obtain feedback from service users, relatives and others who have involvement in the home this information has yet to be assimilated and reported back. Although residents meetings are now being held it was evident from minutes of the meetings that the agenda is being set by the staff rather than service users limiting their opportunity to fully participate. 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. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 the following standard(s): 3 Not all service users referred via care management arrangements had a copy of the care management assessment available. EVIDENCE: The care records of five service users were inspected. All included a detailed assessment of care needs carried out by the home. However, a formal community care assessment was not available in three of the records examined. For individuals referred through care management arrangements, a copy of the care management assessment must be obtained and kept on file to ensure that the care needs of the service user have been fully assessed by those trained to do so and can be adequately planned for and met by the home. A requirement is to be stated in this area. Brymore’s application to provide intermediate care for up to 5 people requiring nursing care was approved by the CSCI in July 2004. The home is currently undertaking building work to provide dedicated accommodation. The variation to the home’s registration has given the home until December 2005 to satisfactorily complete the work. Therefore, whilst the home is continuing to progress this matter within the timescale set out in the registration certificate, Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 9 no requirement will be made regarding this standard. This will be further reviewed at the next inspection. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10&11 Care plans are not being drawn up using a holistic approach resulting in service users social care needs not being fully addressed Service users healthcare needs are comprehensively addressed. Although the home has robust policies and procedures in place in respect to the management and handling of medication, service users are not being encouraged where appropriate to take responsibility for their own medication. Service users are treated respectfully and their privacy is maintained. More consultation is required with service users, family or friends around their personal wishes and instructions at the time of death. EVIDENCE: Five care plans were inspected. Health care needs were comprehensively addressed. There was clear evidence of assessment and monitoring in relation to pressure sores, continence, mobility, nutrition and weight monitoring. Daily recording takes place for each service user and risk assessments are on file and regularly updated. Monthly reviews of care plans have been carried out. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 11 However, there was no evidence to indicate that service users or their relatives, where appropriate, have had any input in the care planning or reviewing process. In addition, the social care needs of service users have not been adequately addressed. The manager has consulted with the Care Homes Support Team on this matter and has obtained a copy of a “Life Review” form with a view to developing a social care plan tailored to individual service users’ needs. However, this is yet to be implemented. The previous requirement in this area therefore remains unmet and is restated in this report. The home has robust policies and procedures for dealing with medication and self administration of medication. Trained staff administer all medication only. At the time of the inspection it was evident a previous requirement to include within the policy the retention of medication for 7 days following the death of a resident had not been addressed. However, immediately following the inspection a revised copy of the medication policy was made available. Consequently, this requirement is now met. A sample of Medication Administration Record (MAR) charts was inspected. One gap was found in that the medication had been administered but not signed for. Controlled drugs kept within the home were stored appropriately and recording and stocks were accurate. However, the majority of the medication records inspected did not have photographs to assist in the identification of service users when administering medication. This places service users at risk of being given incorrect medication. Therefore, a requirement will be stated in this area. In relation to service user plans sampled, it was clear that risk assessments had not been completed with all services users to establish whether they wish to or are able to manage their own medication. Furthermore, despite service users in intermediate care having lockable cabinets in which to store medication for the purpose of enabling them to self administer their own medication this was not being adequately facilitated. Where possible service users should be supported to manage their own medication to encourage their independence. A previous requirement in this area therefore remains unmet and is to be re-stated in this report. The majority of the service users with whom the inspector had contact were well dressed and well groomed. One service user reported that a hairdresser visits the home weekly. Other service users spoken to stated that they always receive their post unopened, are able to see their visitors in their own rooms and that staff always knock before entering their rooms. Observation was that staff interaction was warm and respectful. There was evidence of personal care being recorded daily within service user plans but individual bathing and showering preferences were not specified. Moreover, it was noted in the care plans that were examined that many of the service users were being given bed baths more regularly than bathed or Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 12 showered. This compromises service users dignity and rights to be treated with respect. In respect to the previous requirement in this area this has only been partially met and will be re -stated as a requirement in this report. In respect to issues of death and dying, the home has a policy and procedure in place. Yet, from the plans looked at there was little evidence that this issue has been addressed with service users to ascertain their personal wishes or instructions. It was reported that many of the service users do not want to discuss the matter, particularly on admission. However, it is important efforts are made to sensitively consult with service users or family/friends about this. A recommendation is to be made that this is undertaken. A further recommendation is to be made about the organisation of service users personal information. In addition to the standex files, each service user has a box file which holds loose letters in relation to hospital appointments, exercise programme sheets, would care instructions and risk assessment forms relating to falls and incontinence. The information arranged in this way is confusing, not easily accessible and could also easily be misplaced. The use of clip files and dividers would be advised. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 & 15 The home needs to expand and consolidate the improvements introduced by the activities co-ordinator to further ensure service users individual recreational interests and needs are met. Relatives and friends are able to visit freely so service users are able to maintain relationships of importance to them. Although service users opinions of meals were varied, evidence indicates that they are offered a healthy diet in a pleasant environment. EVIDENCE: As previously mentioned, the activities co-ordinator has enabled more time to be dedicated to involving service users in group activities which involve them doing a lot of arts and crafts in relation to the reminiscence projects undertaken. The co-ordinator also ensures that each individual service user has time spent with them. A folder is kept detailing the work completed with service users but this was not available on the day of the inspection. The coordinator also stated at present these activities are not formally evaluated with service users to assess their effectiveness or appropriateness. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 14 The home does provide other activities within the home including bingo, karaoke, church services, visits from a local drama group and music sessions from visiting musicians but a weekly schedule is not provided. Service users spoken to said that they enjoy the activities provided within the home. However, it was also mentioned that they would like the opportunity to do more outside of the home such as to go shopping or a day trip to the seaside. Previous recommendations in this area have only partially been met. Therefore, in this report a requirement is to be stated that a detailed record is kept of all activities provided by the home and feedback forms are developed to obtain comments from service users to ensure activities and leisure interests match their personal expectations and preferences. Relatives and friends were observed visiting service users of the home throughout the inspection visit. Feedback from service users was that they receive regular visits and that family and friends are made to feel very welcome within the home. Feedback received from service users about the food was varied. One service user described the food as “bland” whilst another stated that although generally happy with the food it would be nice to have more variety. It was reported that previous attempts to vary the menu have proved unsuccessful. Overall, the menu does provide a balanced healthy diet. The inspector was present at lunch and the food served was hot, service users appeared to enjoy the food and they were given sufficient time to eat. However, it is important that service users’ personal preferences are catered for as much as possible. In addition, although the menu does now include the full range of breakfast and evening options, which, meets the previous requirement in this area, the format of the menu is still not very clear. Therefore, in this report a recommendation is to be made for the menu to be revised to make the choices available more explicit. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Although the home has a complaints policy in place and there are systems enabling service users to complain, these have not been made as accessible as possible resulting in a lack of awareness from service users about how to make a complaint or that there are other people than staff they can complain to. Service users are being placed at risk of abuse as not all staff are informed about the adult protection policies and procedures or have received training. EVIDENCE: There is a complaints policy and complaints records but there were no complaints recorded in the book. The inspector was not confident that the lack of complaints was because everyone was completely satisfied with the service after speaking to service users, who fed back that they were unaware of the home’s complaints policy or that they are able to contact the Commission for Social Care Inspection directly if they are not satisfied with how their complaints are being managed by the home. Also, it was noted that the complaints policy placed on a notice board in the entrance hall of the home was not at eye level and was written in small print making it inaccessible for service users, relatives and friends. This was addressed immediately following the inspection in that a revised complaints policy written in larger print was made accessible to the inspector. However, it is essential that all service users are made aware of the home’s complaints policy and procedures and that they are confident that complaints will be dealt with fairly and swiftly. All complaints including informal ones need to be logged Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 16 and a record kept of the homes response. This was a previous recommendation and will be restated as a requirement in this report. There are has robust policies and procedures on adult protection in place. However, the majority of staff spoken to were not familiar with these and reported that they had not received training in adult protection. This needs to be addressed and a requirement is stated in this area. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users live in a safe, well-maintained environment. There is access to safe and comfortable indoor communal facilities. The outdoor communal facilities in relation to the garden is safe but attention needs to be paid to ensure that the drive at the front of the home remains accessible to service users and visitors at all times whilst building works are being carried out. The home is clean, pleasant and hygienic. EVIDENCE: The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained meeting service users individual and collective needs in a comfortable and homely way. The communal areas on the ground floor are well maintained and decorated to a good standard and there is easy access to the garden which is tidy, safe, attractive, private and allows access to sunlight. Furnishings used within the home are of good quality and domestic in character. There is a passenger lift that is in good working order. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 18 The home has until December 2005 to complete building works to complete a dedicated space for the intermediate care service users. On the day of the inspection, the driveway was completely blocked with vehicles belonging to tradesmen. This presents a health and safety risk to service users, visitors and staff. Easy access to the home needs to be made available at all times so that particularly in cases of fire or sudden illness emergency services are not prevented from approaching the home. A requirement is stated in this area. The home is kept to a high standard of cleanliness and no offensive odours were detected. In respect to standard 22 this was not inspected. However, there has been some confusion around a previous recommendation stating the home had to undertake an OT assessment of the building. The registered person has informed the inspector that this has proved difficult to arrange with both private and statutory organisations consulted not providing this service. A comprehensive health and safety risk assessment of the building that was recently carried out was made available to the inspector immediately following the inspection. Consequently, this recommendation will not be carried forward in this report but will be further checked and discussed with the registered person at the next inspection. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 &30 Service users have not been adequately protected by the home’s recruitment policies. There are gaps in the training of staff. This potentially could affect their ability to carry out their work to a competent standard. EVIDENCE: A check of five staff recruitment files was carried out. Not all contained the necessary documents required by regulation. Two of the files only had one written reference and on one file there was no photograph. Criminal Record Bureau checks were not present on any of the files examined. It was reported to the inspector that these are kept in the safe. The administrator, who would have been able to provide access to these, had left for the day so these could not be checked during the inspection. It is essential that all recruitment records are obtained prior to staff begin working. This standard is not met and will be stated as a requirement in this report. As previously mentioned the majority of staff spoken to stated they have not received training in adult protection. It is essential that all staff receive training in this area to uphold the safety and protection of service users. (See requirement 9). In relation to a previous requirement that a review of training Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 20 provided to staff must be undertaken in relation to supporting people with memory issues and/or mental health problems needs, the inspector was informed that staff had recently received training on dementia and also dealing with challenging behaviour. However, the requirement also stated that any skills and training shortfalls must be appropriately addressed. Although, it is evident by those staff that have not received training in adult protection that there are deficits in terms of training received by staff, this was not fully inspected and will be checked at the next inspection. Therefore, this requirement will not be re-stated in this report. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 &36 There are inadequate quality assurance systems in place to ensure the home is run in the best interests of service users. Staff is not being appropriately supervised. EVIDENCE: The home does not have adequate formal quality assurance systems in place. A questionnaire was drawn up internally and completed seeking the views of service users relatives and other professionals involved in the home. Yet, this information has not been assimilated and reported back. In addition, there was no further evidence of other forms of self - monitoring. In relation, to service user’s meetings, evidence was seen to indicate that these have been held and relatives are also welcomed to attend. However, from the minutes, it was evident that the agenda was set by the staff rather than service users being asked for topics for discussion. This limits service users’ participation and the effectiveness of the meetings. The requirement in this area therefore remains unmet and will be re -stated in this report. A further recommendation is to be Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 22 stated that the home consider the introduction of an independent externally recognised quality assurance system. In addition, it is recommended that minutes of resident meetings should clearly record whether service users are asked for agenda items, specify issues raised and action taken. Staff files sampled did not include evidence that staff are receiving individual supervision. Staff spoken to stated that they do not receive formal supervision but that the registered manager is very supportive and accessible and they are able to speak to her if necessary. This was stated in the last report as a recommendation and has not been met. Therefore this will be re- stated as a requirement in this report. Staff meetings are held regularly of which copies of minutes were seen. Staff reported they found these to be helpful and informative. However, the previous recommendation that names of those taking part in meetings and action taken on points raised was not met and will restated in this report. Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X X Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 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) & (b) Requirement Timescale for action 31/12/05 2 OP7 15 (1) &(2)(c & d) The registered person must ensure service users are admitted only on the basis of a full assessment undertaken by people trained to do so and that for individuals referred through care management arrangements a copy of the care management assessment is obtained and kept on file. 31/01/06 The registered person must ensure that service user’s plans sets out in detail the action which needs to be taken by staff to ensure that all aspects of personal and social care needs of the service user is met and the plan is also drawn up with the involvement of the service user and signed by the service user whenever capable and /or representative. Previous requirement of 31/03/05 not met. The registered person must ensure that the systems in place for recording and monitoring the administration of medication are used consistently and effectively DS0000007010.V251564.R01.S.doc 3 OP9 13 (2) 31/12/05 Brymore House Version 5.0 Page 25 4 OP9 13(2) 5 OP9 13(2) 6 OP12 12(4) (a) 15(2)(c) 7 OP12 16 (2) (m) & (n) 8 OP16 22 specifically staff sign the medication administration records for all medication administered. The registered person must ensure that staff are able to identify service users by ensuring all individual medication records have a photograph in situ to ensure service users are in receipt of the correct medication. The registered person must ensure that where appropriate service users are able to take responsibility for their own medication if they wish, within a risk management framework. Previous requirement of 31/03/05 not met. The registered person must ensure that the arrangements for personal care giving including bathing and washing ensure that service user’s privacy and dignity are respected at all times. Previous requirement of 31/03/05 partially met. The registered person must ensure that service users are consulted and feedback obtained on social activities and leisure interests that are provided to ensure that they are given opportunities to partake in recreational and leisure activities in and outside of the home that are suited to their needs, preferences and capacities. Further, that information about activities to be provided is circulated to all service users. The registered person must ensure that the complaints procedure is accessible to all service users, relatives and friends and that all service users are aware of their right to DS0000007010.V251564.R01.S.doc 31/12/05 31/01/06 31/12/05 31/01/06 31/12/05 Brymore House Version 5.0 Page 26 9 OP18&OP3 0 13(6) & 18(1)(c (i)) 10 OP19 23(2)(a) & (o)(4)(b) 11 OP29 19 &Sch 2 12 OP33 24 13 OP36 18 (2) complain, how to complain and supported to voice any current concerns they may have. The registered person must ensure the safety and protection of service users from forms of abuse by ensuring all staff working within the home are aware of adult protection policies and procedures (including whistle blowing) and have received training in this area. The registered person must ensure that whilst building works are being undertaken, the drive way remains accessible to service users and those visiting the home at all times and in the event of an emergency the home is easily accessible for the emergency services to approach. The registered person must ensure that staff do not begin work in the home until all documents required by regulation are in place. The registered person must ensure that an effective quality assurance system based on seeking the views of and reporting back findings to service users, their families and other stakeholders is in operation at the home. Previous requirement of 31/03/05 not met. The registered person must ensure that all staff receive regular individual supervision and that each session is formally recorded and kept on staff’s files. 31/01/06 30/11/05 31/01/06 31/01/06 31/01/06 Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP11 Good Practice Recommendations The registered person should consider the use of clip files and dividers to keep additional information in respect to the health, personal and social care needs of service users. The registered person should try to ensure that all service users and where appropriate relatives/friends be consulted about their wishes and instructions at the time of death and recorded as part of the service user plan. The registered person should try to ensure the format of the menu is revised to show more explicitly the choices available to service users. The registered person should consider using an externally recognised professional quality assurance tool in the home. The registered person should try to ensure that minutes of resident’s meetings record that service users are asked for agenda items, specify the items forwarded and action taken on points raised. The registered person should try to ensure minutes of staff meetings include all those in attendance and action taken on points raised. 3 4 5 OP15 OP33 OP33 6 OP36 Brymore House DS0000007010.V251564.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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