Inspection on 18/10/07 for St Brannocks

This inspection was carried out on 18th October 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Brannocks 16/10/08

St Brannocks 26/10/06

St Brannocks 03/11/05

St Brannocks 12/05/05

St Brannocks 25/11/04

St Brannocks 12/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Brannocks 7 Cromer Road Mundesley Norwich Norfolk NR11 8BE Lead Inspector Mrs Judith Last Unannounced Inspection 18th October 2007 04:40 St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 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 St Brannocks DS0000027524.V353399.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 Adults 18-65. 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. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Brannocks Address 7 Cromer Road Mundesley Norwich Norfolk NR11 8BE 01263 722469 01692 650330 janithhomes.com@btinternet.com www.janithhomes.org Janith Homes Limited 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) Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: St Brannocks is a care home providing personal care and accommodation to 7 adults with a learning disability. A company operates the service and service users attend day services at the company’s main home, The Rookery. St Brannocks stands in the Norfolk seaside village of Mundesley and is easily accessible to all community facilities and to bus links to the city of Norwich. The home has its own transport. The home is located in an Edwardian house and all service users have their own bedroom. The home has enclosed rear gardens with a patio, lawns, flowerbeds and a greenhouse and vegetable garden. Inspection reports are available, but would need to be explained to residents. The company’s website, (www.janithhomes.org), says that inspection reports are available on request. The charges are unspecified in the Service User’s Guide on the Internet. In addition to weekly charges there are charges for transport and staffing to requested activities, (but not for health care appointments), hairdressing, dry cleaning and personal spending. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We spoke to the manager, a member of staff and four people living at the home. We also spoke to a relative of someone living at the home. All of the people living at the home filled in questionnaires and five of their relatives wrote to us. We got other information from the form the manager sent to us before we visited and from records that we saw at the home, as well as from listening and watching what was going on. We were at the home for four and a half hours into the evening. It is clear from comments that the service has gone through a difficult time that has led to some slippage in standards. These can be attributed to big changes in staffing and management. Feedback shows that relatives have recognised this, but also that there has been significant improvement since the new manager and staff team started work. Overall, the service is adequate at the moment. We know it has been through a difficult period with three different managers and all new staff. However, the drive and enthusiasm of the people now working at the home including the manager mean that we think that people will benefit from great improvements in the future. (This is providing the staff team and management remains relatively stable). What the service does well: People have lots of opportunities to join in activities, inside and out of the home. They can join in things to do with the running of their home and are able to get their ideas across to the staff and manager. People live in a homely environment with their own possessions around them. This includes lots of the things they have made in artwork and things like music or videos and DVDs that interest them. People living at the home get on well with the new staff and say that they feel well cared for. We saw that people sat together chatting with one another and with staff and that the atmosphere was calm and friendly. Minor disputes between people living at the home are dealt with quietly and without fuss. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There are some things that need to happen by law. The guide for people who might want to live at the home does not contain the information the law says it must have. The law about this was changed in September last year, and the information needs to be revised so that people or their representatives can make an informed decision about whether they want to live at the home. Staff need to have training in how to administer medicines and records need to be clearer and complete. This is so people are protected by the way medicines are handled and so records confirm people have the medicine they need to keep them well. There have been a lot of staff changes and these mean that staff do not have the qualifications they need. We told them they had to sort this out the last time we visited, but changes mean it has been difficult for them to complete this properly. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 7 New staff must have all the checks they need before they start work and always work with experienced staff until later checks are completed. This is so people are protected from anybody unsuitable working at the home. Where things to do with fire safety go wrong they need to be put right very quickly in order to keep things as safe as possible for people living and working at the home. There are some other things that could happen to improve things even more and these are set out in the full report. 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. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents could be confident that their needs would be assessed. There must be improvement in the content of the service users’ guide so that people, or their representatives, have access to the full information, however they choose to gather it. EVIDENCE: The manager was not able to locate any up to date statement of purpose in the home. The information on the company’s website, which includes a service user’s guide, does not show the range of fees or contain the information about these that the revised regulations require. All of the terms and conditions/contracts seen on files sampled show that fees are “from £1100”. This means that the contracts do not specify for each individual or their representatives what is the particular charge for the service. A requirement has been made. There has been only one admission recently and that person came from another service owned by the same company. Assessment information seen on files is good and shows that a range of detail, including someone’s likes and dislikes as well as strengths and needs would be collected. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can make decisions about their lives and are involved in planning the care and support they receive. There could be improvements in setting out individual goals and also in the accessibility of information but we recognise that the manager has had little time since taking up her post, to develop systems further. EVIDENCE: The manager has only been in post since March. For some time before that there was a lack of consistent management, and she has identified the need to update all of the information about people’s needs because this had not been kept up to date. She has revised recording systems and staff access care plan files on a regular basis. There are clear assessments, records of likes and dislikes, and records of strengths and needs. These show what support people need to complete tasks. One staff member gave us consistent information about what should be recorded where and what the recording systems were. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 11 The information people gave us about what they liked to do and the kind of support they needed matched what was in plans. People do not have their care plans in their rooms, but told us where they were and three people who were asked, said that they could look at them if they wanted. The manager has plans that people should be able to have a copy of their own plan. However, at present, these are only available in one format. Work would be needed to make the information meaningful for people to access independently. See recommendation. Staff are aware of the need to explain things to some people and to give time for them to assimilate information and respond. Everyone we spoke to said that the staff talked to them about the sort of things they wanted to do and the support they needed. There is some information about goals, but these are often combined reflecting several different areas. In some cases identified and recorded goals are very limited. We discussed with the manager that if goals were recorded separately and broken down into smaller steps, it would be easier to recognise and encourage progress. A recommendation has been made. Despite goals not always being clearly set out, a relative describes someone as coming on in “leaps and bounds”. One relative we spoke to says that a resident has made good progress since the new manager arrived. Plans set out clearly any issues to do with behaviour, and the stages of escalation this might go through. They record at each point, the interventions that staff should make. However, in later stages the intervention relies on what could be perceived as “threats” to write things down in their books, and then about telephoning family members, (this has been agreed with family members). The manager says that these interventions normally mean that behaviour does not escalate through the recorded stages. The manager may like to discuss more positive interventions such as defusing and distracting techniques with other relevant persons, (psychology, behavioural specialists). A recommendation has been made. Everyone completing a comment card says that they are able to make their own decisions. Risk assessments record where there may be restrictions or the person may be vulnerable and so not wholly be able to make particular decisions. There are risk assessments that cover individual activities and the measures needed to reduce any associated risk to an acceptable level. These were signed by the manager, the person’s keyworker and also by the person concerned. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 12 People told us that they were involved in lots of things to do with the day-today running of the home. Three people told us they had been involved in working in the garden. Everyone said that they were involved in day-to-day things like keeping their rooms clean, and that they now take it in turns to help prepare the main meal. There are three budgerigars that people have as pets. One relative commented in writing that perhaps a person could be given more support or supervision when ironing clothes, as sometimes these were not as presentable as they could be. People we saw were in casual clothing and so we could not verify that this was a problem, but the manager may like to take it into account when setting out support and supervision needed. One person told us that they had recently helped with staff recruitment. There are records showing that residents’ meetings take place with staff support to manage these. People can be made aware of things that are happening in the house, any changes or plans. The last one was in June. There are also full “house meetings” which involve the staff team and the people living there. The last one was in August. Further meetings are planned and so no recommendation has been made. There are questionnaires about what people think of the home carried out to monitor their views of the quality of the service. All of the comment cards show that people feel that staff treat them well. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their skills. Social and recreational activities meet individual’s expectations. There is room to improve employment opportunities for some people. EVIDENCE: People told us in their comment cards, that all of them felt they had lots of things to do. People told us what some of these were. The manager’s selfassessment of the service recognises that there could be improvement in establishing opportunities for employment, given the abilities of some of the people living at the home. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 14 Duty rosters show that there are two staff on shift. We saw staff spending time talking with people living at the home and in the kitchen with meal preparation. One relative comments that there are sometimes staffing constraints and we are aware that this was difficult earlier in the year following management changes and the loss of experienced staff. People clearly enjoy the opportunities they have to do artwork at the company’s Art barn. One person does a lot of needlework and has exhibited this. One person showed us some of the stitching they were doing in their own time and were clearly enjoying this. Two people told us they enjoyed working at the farm, and three people had enjoyed their recent fishing trip. People told us they also use the local library and social club. Relatives say that people are able to keep in contact with them. One relative we spoke to confirmed this. Records and observation is that sometimes people go to families to spend time with them. Observation is that relatives are also involved in formal reviews of people’s care if appropriate. Care plans recognise issues of sexuality and what support people might need. We saw that people who are able to manage them, have keys for their rooms. One person who had bent the key the last time we visited had been given a new one, according to the manager. One person showed us their keys and also has one for the house. People told us they join in with housekeeping things and that they had changed the menus with help from staff – also that they now take it in turns to help prepare meals. One person prepares their own food and has a different menu, having their own kitchen facilities. People say they like the food and can help go shopping for it. People’s weights are monitored so that any problems can be addressed. During the evening meal there was a quiet and unhurried atmosphere and people shared time together round the large dining table. The meal when we visited was shepherds pie followed by apple crumble. People told us they enjoyed it. The person who prepares their own food was going to have bacon omelette and salad. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel well cared for and health and personal care needs are met in the way people prefer and need. EVIDENCE: Six out of seven people say they felt well cared for and one does “sometimes”. Four relatives say that the home always meets the needs of their relative and one says this happens usually. The person who says this usually happens goes on to comment specifically that the home was ‘never bad’ but has improved immeasurably since the new manager started a few months ago. Three of the six say that they are always kept up to date about important issues, for example, if the person has been to hospital or had an accident. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 16 People need limited help with their personal care based on assessment information and on the manager’s self-assessment. One person needs some help with dressing and undressing, and with bathing and washing. The staff group is predominantly female, but there is one male member of staff and so service users who needed assistance could have support from someone of the same gender subject to duty roster constraints. People could tell us who their keyworkers were and say they like the staff. During the visit to the home, one person told us they were going to bed early (9pm) because they had a day working on the farm the next day. The person had recently purchased an alarm clock to help with getting up when they needed to. Another person told us they went to bed when they were ready. We left at 9.10pm and heard no pressure or discussion from the staff on duty about people needing to get ready for bed. Records are made when people have appointments. On the day we visited one person had collected new glasses from the optician and was clear that these were needed for close work. The manager recognises the need to monitor health care, (based on the self assessment), whether or not people had needed to go to appointments because of health difficulties. Medication is administered from a locked wooden cupboard in the office and is contained in blister packs supplied by the pharmacy. People come to the office for this, bringing a drink with them. The manager says that they have tried via use of compliance aids to encourage self-medication for someone, but it had been unsuccessful. One, who had not administered their own medication before moving to the home, now does so. Supporting risk assessments have not been carried out to show that it is not reasonable for others to manage their own medication and why. The manager has supervised staff in administering the medication and ensures they are comfortable with this before they take on responsibility for it. One person has had experience at another home in the group, and one in their previous employment. Not all staff, (given two of the three started newly with the company in April), have had formal and accredited training. There was one omission of signature of a chart in current use, some concerns that one signature could be misread and some over ordering, with surplus medication needing storage and not being used in date order. See associated requirements and recommendation. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People and their representatives are able to express their concerns, and know how to complain. They feel safe at the home and systems are implemented to help protect them from abuse. EVIDENCE: We had specific comments on the cards that people like the staff and from the interactions we saw, people were clearly comfortable talking with staff including the manager. We heard people chatting in the lounge area during the evening in a way that indicated no anxiety of discomfort with the staff on duty. We saw that people had information about how to complain in their rooms and another copy on the noticeboard in the hall. This contained the number for the Commission. The people we spoke to said they would talk to their keyworkers or the manager if they had any concerns. All of the comment cards show that people know who to speak to if they have concerns about their care. Four out of five relatives know how to complain, and the one that does not, concurs with others saying that the home has always responded appropriately if they have had concerns. We spoke to one person who outlined a concern and says that this was dealt with quickly and appropriately. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 18 All of the people completing comment cards say that they feel safe at the home. Staff do not yet have formal training although this is being arranged and so no requirement is made at this stage. One member of staff, without the training, but having completed induction, clearly identified the need to report any incidents that caused concern. There is clear guidance for staff to follow about the management and checking of any monies they may assist service users in managing. The manager expects that any spending decisions over £10 would be referred to her for consultation. A relative spoken to is aware of the kinds of expenditures staff might assist with. We saw monitoring arrangements for checking receipts and withdrawal slips from the bank. We checked receipts and balances for two people and found these to be accurate. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely, comfortable, clean and safe environment that suits their needs. EVIDENCE: We looked at communal areas and two people’s rooms with their permission. Rooms were warm, comfortable and homely. There has been investment in improving the exterior of the home now building work is completed. The garden is much improved and people have been able to use it and work in it if they are interested. Neither of the front door bells works and in order to make ourselves heard to gain access we had to telephone to tell them we were outside. The manager says that this has been reported for repair and so no requirement has been made at this stage. We saw no immediate hazards to health and safety. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 20 The laundry is sited off the kitchen and this means that linen has to be taken through the area where food is prepared. However, there are no difficulties with continence at present. At the last inspection we were told there were plans to solve this issue by creating a laundry facility on the first floor. This has not yet happened. Areas we saw were clean. The manager has department of health guidance about infection control and the organisation has an infection control policy. Staff do not yet all have training in food safety, but two people are now booked on this. One person has this from a former employer. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. As staff are new to the home, they are not all yet fully and formally trained to support the people who use the service. Recent turnover means it is difficult for the service to have wholly achieved outcomes in this area, although the manager is working towards improvements. EVIDENCE: The home has been through a difficult period with staffing, in that there have been changes of management and experienced staff have left the home. Within the existing staff group, one person has transferred from another of the provider’s homes, and two other people started in April. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 22 The home does not yet meet the standard for half of staff to be trained to NVQ level 2. The manager says that the one person of four listed on the selfassessment as having NVQ qualifications is herself. This means that none of the support staff yet have the qualification. However, one person is already working towards NVQ level 3 and another is “down” to start this. The person we spoke to has submitted an application to do NVQ level 2. See outstanding requirement. We saw recruitment files for two staff starting in April. These show that full employment histories are obtained and enhanced criminal records bureau checks are carried out. However, we saw that there were times, (albeit limited and for short periods), when staff were not always working with someone who had the full necessary clearance and induction. The situation was difficult given the turnover of staff, size of the home and that both the manager and two other staff were new to the organisation. The manager says that staff from “headquarters” provided additional support pending the checks. See outstanding requirement. We discussed that the employment of staff before completion of full checks is subject to certain conditions. These include the receipt of checks showing the applicant is not listed on the register for the protection of vulnerable adults and obtaining all references and identity checks before the person starts work. One person’s second reference did not arrive until after they had started work at the home. Our notes show that a second person started work at the end of April and neither reference was received until May. See requirement. One person has recently helped in recruiting new staff. This is a welcome development and good practice. Staff have completed and are certificated for completion of common induction standards. The manager is trying to ensure that staff have up to date training in a range of areas including first aid, food hygiene and abuse awareness and she recognises the need for systems to record this and identify when updates are due. Staff spoken to confirmed booking for some of the necessary training. Staff have been in post for less than 6 months and good progress is being made. Records of 1:1 sessions (supervision) for staff were seen. These show that the manager is on target to deliver supervision with the agenda and frequency set out in standards. This represents good improvement over the last inspection. The staff member we spoke to is new to care work and describes the manager as very supportive. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has only been in post since March and has had to address difficulties arising from staff turnover and inconsistent management previously. We consider that she shows the drive and enthusiasm to complete her qualification and to continue improvements throughout the service in the future. Both staff and relatives clearly value the impact on improving the service that she has already had. EVIDENCE: The manager has been previously registered, but not in respect of this service. She does not yet have the qualifications considered necessary and set out in standards, but has started work towards these, having 10 modules to do to achieve the Registered Manager’s Award. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 24 We saw evidence that service users are asked for their views and also that some of the suggestions they made for change or improvement according to preference, have been acted upon. For example, residents meeting notes record suggestions and who is responsible for actioning these, as well as whether they have been achieved. There are regular monitoring visits on the part of the registered provider. We checked a sample of records to do with health and safety. These included servicing records for gas appliances and electrical installation. None of these presented concerns. One person is responsible for checking fire alarm call points regularly. These show that a “Dorguard” device for closing fire doors automatically had not worked for a month when it was tested four times. The manager explained that there had been difficulties in rectifying the problem. See requirement. However, we note that the manager has improved measures for fire containment by arranging for additional door closers. There is clear guidance for staff to follow near the alarm panel, which also includes a clear map of zones. St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 2 x St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5 Requirement People who live at the home or who are thinking about moving there, must have the information the law says they need. This is so they or their representatives can make an informed choice about moving into the home. It is also so they can be sure of the arrangements for charges or increases in these. People who use the service must have their medicines administered by staff who have received recent and appropriate training and have been designated competent. This is to help protect people from errors and to make sure they receive the treatment they need safely. Medicine administration records must be properly and clearly signed after each administration. This is so records show that people have had their medicines as prescribed and there is no possibility of confusion between signatures and “codes”. Timescale for action 31/12/07 2. YA20 18.1.c 31/12/07 3. YA20 17, Schedule 3 30/11/07 St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 27 4. YA32 18.1.c Outstanding requirement with timescale of 31/1/07 unmet Staff must have NVQ training to achieve the 50 ratio set out as a minimum standard. 31/05/08 5. YA34 18.2.b & 19.11 This is so staff are properly trained and qualified to understand the work they do and be better able to meet the needs of people living at the home. Outstanding requirement 30/11/07 with timescale for 31/12/06 not met Staff recruited after POVA first checks and full references etc, but pending receipt of enhanced Criminal Records Bureau checks, must be supervised at all times by a named and properly checked staff member until induction and checks are complete. 6. YA34 7. YA42 This is so people living at the home are protected by recruitment procedures, from staff who are unsuitable for the work. 13.6,19 There must be adequate checks completed on staff in line with Department of Health guidance, before staff start work at the home. This is so the manager can ensure people are not put at risk from unsuitable staff. 23.4, 13.4 When equipment associated with fire safety, fails to operate properly, faults must be rectified without delay. This is unnecessary risks to people living and working at the home are avoided and measures are in place to contain a fire should this happen. DS0000027524.V353399.R01.S.doc 30/11/07 30/11/07 St Brannocks Version 5.2 Page 28 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 YA6 Good Practice Recommendations Care plans should be simplified, potentially using easy words and pictures, photographs, video etc, so that people living at the home can more easily understand some of the information and participate in planning their care. Care plans should set out goals for separate areas of care, to show how staff are to support people to achieve them, whether they be desired activities or the need to maintain or develop new skills. Where people’s behaviour challenges and could escalate, the manager should seek advice from other health professionals about alternative and additional methods of responding. This is so early interventions focus more on the positive behaviour of individuals. Where people need support and encouragement to achieve domestic tasks successfully, for example ironing, there may be a need to specify support in more detail. This is so people receive the full support they need to achieve good results. Consideration should be given to providing medication storage that meets the standards. This would improve the security of storage of medicines. 2. YA6 3. YA6 4. YA8 5. YA20 St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 St Brannocks DS0000027524.V353399.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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