Inspection on 31/10/06 for St Brigas

This inspection was carried out on 31st October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

St Brigas 08/11/05

St Brigas 14/03/05

St Brigas 17/06/04

St Brigas 16/12/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 St Brigas 2-3 Jesmond Road Clevedon North Somerset BS21 7SA Lead Inspector Barbara Ludlow Unannounced Inspection 31st October 2006 09:30 St Brigas DS0000008090.V317493.R02.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 Brigas DS0000008090.V317493.R02.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 Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Brigas Address 2-3 Jesmond Road Clevedon North Somerset BS21 7SA 01275 870653 01275 879900 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) Mrs Lynne Whitehouse Miss Anne Ball, Mr David Whitehouse, Mrs June Lloyd Mrs Lynne Whitehouse Care Home 17 Category(ies) of Learning Disability, 18 to 65 years (LD), and registration, with number Learning Disability over 65 years of age (LD(E)) of places St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th and 16th November 2005 Brief Description of the Service: St Brigas provides care and support to seventeen people who have learning disabilities. Situated on a hillside overlooking Clevedon, it comprises two Victorian houses. One quarter of the accommodation is used as an activity centre for people with learning disabilities and is not regulated by the CSCI. The accommodation is located over three floors and access is by means of various staircases. The lounge and dining room overlook the well maintained garden at the front of the building. The home is located close to a park and the town centre is 10 minutes walk away. Four partners own St Brigas, one of whom is the manager, and another provides the maintenance support. They meet regularly to review and discuss the home. The current range of charges is £340,07 to £1138.48 (figures taken from recent account records) St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key standard inspection was carried out in one day over a 6 hours period by two inspectors for CSCI. This inspection was very positive and overall a judgement of excellent was made. The Registered Manager Mrs L Whitehouse was on duty at the home and made time to assist with the inspection process. Business partner Mr D Whitehouse was on duty and available throughout the day. The inspectors were introduced to staff in the home and day centre. The home was full with seventeen residents listed. Sixteen service users were seen during the day in the home, the day centre and when returning from trips out and walks. One service user was in hospital. Interactions between staff and service users were observed during the time the inspectors spent in the communal areas of the home with the service users. Photographs were seen displayed of service users, displays of artwork in the day centre and around the home. A tour of the premises was made with Mrs Whitehouse. Bedrooms were sampled and all communal areas were viewed. The kitchen was seen and the cooks training and catering records were seen. Lunch was seen served in the dining room for the resident service users at home and all those attending the day centre. Records were inspected during the afternoon. These included care plans, financial records and contracts. Maintenance and servicing records for fire safety equipment and services. Mandatory staff training and training events. Quality assurance policy and surveys carried out were seen. The action taken as a result of surveys was discussed. What the service does well: St Brigas is very homely. Residential service users are part of a community and appear very relaxed, comfortable and look very well cared for. The care of the individual is paramount and staff know the service users very well. Key workers are allocated to the service users. Some have been with their resident for many years. Key workers play a very important role in the life of the resident and are fully involved with care planning and reviews of care. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 6 There is a very open management response to inspection and the development of the service. The Registered Manager works hard to keep up to date and research best practice for the care of the residents at St Brigas. Staff have been encouraged to attend workshops and seminars to develop their knowledge base, skills and achieve best practice. Working with community professionals the staff have enabled residents to develop life skills and manage their own behaviours so that progress as individuals is a continuum. This was also seen in the individual dementia care planning work Mrs Whitehouse is currently undertaking. Feedback had been received from a visiting professional who spoke highly of the care staff and management. This was in praise of the care and attention to help residents cope at very difficult times in their lives. Residents can freely access all communal parts of the home and their personal bedroom space is private and is respected as such. Service users and staff are very comfortable around the home, which has a calm and friendly atmosphere. What has improved since the last inspection? What they could do better: Some older care records have pencilled in reviews. These should be overwritten before archiving or when reviewed in full. This will prevent the entries fading or being erased. As rooms are redecorated or upgraded the safety of hot surfaces should be individually re-appraised. For one bedroom there is a proposal for the addition of an en suite toilet. This improvement will involve moving the radiator; the fitting of a cool surface style radiator or a suitable radiator cover at that time is therefore recommended. One bedroom floor covering and one toilet were malodorous. Attention to a review of the floor covering and odour control is recommended. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 7 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 Brigas DS0000008090.V317493.R02.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 Brigas DS0000008090.V317493.R02.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): 1,2,3,4,5,Quality in this outcome area is excellent. There is a full and detailed admission process at St Brigas to ensure that the prospective service users needs can be met. This whole process is thoughtfully and sensitively carried out. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The admission process was discussed with the registered manager. There is a brochure for use by prospective residents, with photographs and symbols supported by some words. The home also provides a briefer brochure for casual enquiries. New residents are only taken after full consideration of their assessed care and support needs to ensure that these needs can be met at the home. Admission to the home is assessed for the impact upon and the best interests of the other service users in residence. The Manager stated that this whole process and the trial period could take up to six months. There had been no new admissions since the last inspection. One person was assessed to see how they adjusted and settled into life at St Brigas over a period of time. It was evident that this service user had settled in very well, St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 10 there was an increase in their confidence and in their general social skills, which was pleasing to observe. Time was spent with the homes administrator to review service user finances and sample contracts. Contracts and charges were carefully recorded. 14 of the 17 service users pay £8 per month to the local pharmacist for their blister packed medication, medication review and storage. This was not declared on the pre inspection questionnaire as an extra cost to the resident. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 11 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): 6,7,8,9,10 Quality in this outcome area is excellent. The service user plan is developed in partnership with the service user, based on an efficient assessment. The plan clearly sets out how specialist requirements will be met through positive and planned interventions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector’s sampled two residents care plans and associated documentation in depth. Care plans showed clear goals, and reflected the way staff are supporting residents to achieve these step by step. Written response strategies reinforce the persons own point of view, and remind staff of the need to praise any successes. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 12 Care plan updates and the daily records showed a clear progression towards meeting goals. The team has been very creative about using rewards and compromises in helping the person achieve improvements. The registered manager is currently working on creating very detailed care plans for a resident who is developing dementia. This was seen as an innovative piece of work with this service user, which is commendable. Risk assessments covered a broad range of aspects of the person’s daily life, including their individual level of vulnerability to abuse. Risk assessments also looked at the potential risks to staff, and the environment or practice has been adapted to reduce the risk where practicable. These assessments included looking at alternative ways of enabling the person to carry out the desired activity safely. For example, one person is not able to use the homes kitchen facilities safely, so the risk assessment looks at means of keeping him out of the kitchen but also identifies the day centre facilities as a safe place for him to practise his cooking skills. Care related documents are reviewed on a monthly basis, and almost all reviews included an adjustment to the teams strategy, either because the person is achieving success or because the team has decided to take a step back and try a different approach as their previous agreed strategy was not working. Where a goal has been achieved, the documentation is left on file and is reviewed for a while afterwards to ensure that the goal is still being met. These written guidelines to staff were very explicit and helped to promote a consistent approach. Their effectiveness is demonstrated by the evident progress that residents are making. Residents’ files included picture and symbol versions of their care plans and risk assessments for staff to go through with the person. Useful links have been built with other local health care professionals. The local Community Team for People with Learning Disabilities has been giving intensive input regarding the development of effective strategies for managing one persons behaviour, and has also been giving training to the staff team. This persons psychologist and psychiatrist have also been closely involved with this work. The home has been working very closely with the local GPs surgery regarding the highly specific health care needs of two other residents. One of the residents is currently in hospital, but staff are visiting them daily and supporting the hospital staff in their care. Communication aids were sent to the hospital for them to use with this service user during their stay. Some of the residents have also been taken to visit at the hospital. St Brigas DS0000008090.V317493.R02.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): 12,13,14,15,16,17 Quality in this outcome area is excellent. The home understands the importance of enabling younger adults to achieve their goals, follow their interests and be integrated into community life and leisure activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has a weekly timetable, with a range and frequency of activities tailored to meet their own needs. These are supported by clear written guidance about the persons preferred daily routine. There is also a pictorial version of the timetable, with photographs of the staff that might be involved in working with that person on each activity. Residents files contain a section called About Me with pictures and symbols describing what is important to that person. In this section, response St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 14 strategies are phrased very clearly from the persons own point of view, and include symbols and simple words so that staff can go through these with the person. Each resident has a diary with regular entries showing how staff are working towards the persons care plan goals, following the agreed strategies. These diaries also show the variety of activities that are being offered to the person, and the social contacts that they are being supported to keep up. One person who has difficulty communicating carries a photograph diary with them, so that staff in the home or day centre and relatives can be kept up-to-date with the service users daily life. St Brigas DS0000008090.V317493.R02.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): 18,19,20,21 Quality in this outcome area is excellent. Staff ensure that personal support is flexible, consistent and responsive to the changing needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is using a yearly health-care plan sheet, which includes dates of the last and the next due check of the person’s general health, eyes, dental health and hygiene. The inspector suggested that reminders are added to this checklist to assess whether a less regular test, such as health screening e.g. when a cervical smear, is needed. Health screening decisions are made on an individual basis with medical guidance. The inspectors suggested recording the decision and rationale in the persons health care plan. The pre inspection information indicated that nine staff that are trained to administer medications. The management of medications was inspected. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 16 The medicines held were appropriately and safely stored, not a lot of stock is held at the home. The manager stated that the service delivered by the local pharmacist is very helpful and medications are regularly reviewed. There is a charge by the pharmacist each month for blister packed medication, medication review and storage; this is passed on to the individual service user. 14 of the 17 service users pay this monthly charge of £8.00. Medication Administration Records were complete for all medication administrations. There were a small number of entries where the quantity received had not been signed. Care must be taken to complete the MAR’s to ensure that an audit trail is complete. Staff signatures are recorded for reference. Overall the medications management was satisfactory. St Brigas DS0000008090.V317493.R02.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): 22,23 Quality in this outcome area is good. There is a clear complaints procedure at St Brigas. The home has information notices around the home to inform service users, helping them to raise any concerns / complaints. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been made to the home or to CSCI since the last inspection. There are picture based information notices in the communal areas of the home to help service users understand what behaviours are acceptable and what do not to be tolerated by them. The registered manager is working on a new complaints procedure with one of the residents to ensure that the pictures used in it are meaningful. The service users at St Brigas are comfortable in their environment and all looked well cared for. Interactions with staff were positive and mutually respectful. Recruitment practices were safe at the last inspection. There have been no staff leave or new staff starting work at St Brigas since the last inspection. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 18 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): 24,25,26,27,28,29,30 Quality in this outcome area is, good. St Brigas provides a homely environment that is appropriate to meet the specific needs of the residents who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Brigas is a warm and welcoming home. The gates to the home are locked for the health and safety of one service user, who is unsafe alone on the potentially busy roads. There is no incursion on their freedom, as staff manage this situation by escorting the service user on trips out to the shops and for walks. One staff and two service users were seen returning from a walk to the sea front during the afternoon, they had also been accompanied at a discreet distance by the home’s cat. There are lots of photographs of the residents and examples of their artwork around the home. The day centre next door is an integral part of the home in as much as the service users who attend day care have more of their personal art and crafts on show there. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 19 The Snoozlum (sensory room) has been completed and is now in use, residents are accompanied to use this facility. The Snoozlum is situated in a garden room adjacent to the woodwork skills facility. Inspectors saw most of the residents bedrooms, and it was obvious that staff have given thought to the needs and preferences of each person. Most bedrooms were personalized with pictures, ornaments and soft furnishings, but one is kept quite bare, as this is how the occupant wants it. One bedroom requires redecorating. The occupant of this room was in the habit of scratching the plaster off the walls in several places, the manager explained that her team had been working with them to change this behaviour. Their approach has proved successful, and the manager plans to redecorate this room in the next month. Privacy is upheld and staff support and manage personal private space in such a way that will not upset the service user. Residents are encouraged to be part of the whole at St Brigas by being included and supported in daily life. Equipment around the home is made as safe as possible, to protect service users from harm. Risk assessments have been made for hot surfaces in bedrooms. The inspector was informed that the radiators are programmed to go off at night, a time when the home has only sleeping night care staff offering emergency cover. It is recommended that with any future environmental upgrading, potentially hot surfaces of radiators / pipes be protected in some way to further minimise the risk of burns should someone fall against one. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 20 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): 31,32,33,34,35,36 Quality in this outcome area is excellent. Service users are well supported by a dedicated staff team. The key worker role is well established and is effective. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager and her deputy were on duty during this inspection. There would normally only be one senior on duty but the manager had come in to do some additional work on a project. Three support workers were in the home at the start of this inspection, and the Cook came on duty at 11 oclock. There were two cleaners working in the morning, one of whom later on worked in her other role as the administrator. Mr Whitehouse, another of the owners who is also the homes handyman, was also working. Four of the homes seventeen residents were at home, one was in hospital. Some residents were using the day centre next door, where six staff were on duty. Several residents from other local care homes were also using the day centre. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 21 Morning staff levels are usually high to allow one-to-one support for appointments in the community or for social outings. The senior on duty during the early shift starts work at 7 a.m. to help with residents personal care, and then resumes a management role. There are no waking night staff. Two staff are on the premises and available to respond to the call bell in an emergency or if someone is ill during the period between 11 pm and 6am. The registered manager shares this rota to monitor the home or in response to particular needs. None of the current residents were reported to need nighttime checks or supervision once settled. There have been no staff leave or new starters since the last inspection. Recruitment practice was found to be good at the last inspection. There has been no use of agency staff since the last inspection. Of the 12 staff at the home, 9 have NVQ Level 2 or above which is 70 . 9 staff hold first aid certificates and 9 staff are trained to administer medications. The registered manager and two staff recently attended a three-day conference in Loughborough to acquire more information about a syndrome that affects some of the residents. The registered manager is a trained manual-handling trainer, and provides this training for staff. The registered manager is starting to plan some dementia training sessions with staff to look at how they can adapt their practice and the environment in response to one persons changing needs. This innovative practice is commended. Staff supervision is developing, not all staff had a record of supervision on their file. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 22 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): 37,38,39,40,41,42,43 Quality in this outcome area is excellent. Service users benefit from the home being well managed. There is clear leadership and a strong focus on the outcome for service users in all management and development decisions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is also qualified to teach classes in the day centre, which is affiliated with the local Weston College. This allows some back up in the event of ill health or absence. The deputy manager has just completed NVQ4 and was available during the inspection to assist as required and was present for some of the feedback. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 23 The Communications book reflected a regular exchange of information, occasional requests for equipment, and messages of thanks to staff. All records seen at this inspection were appropriately and safely stored. Access was appropriately restricted. Quality Assurance is taking place. A pictorial service user survey was undertaken to assess their views on the quality of food. The management and owners of the home have an annual premises quality audit. Staff are now assessing the home on a monthly basis to look at areas for improvement. The last survey undertaken with families was reported to be in May 2006. Servicing and maintenance records were sampled: Fire alarm checks are carried out on a weekly basis. The fire doors and smoke detectors are also checked each week, as are the emergency call bells. The last fire drill was held on 27/10/06. The owner organised a drill and evacuation with challenges to the exit routes, this was reported to have been successfully completed win 2 minutes. Monthly checks are made on the emergency lighting and fire exits. The fire alarm system is serviced annually. Water tanks are checked on a six monthly basis and the hot water delivery temperatures are checked on a weekly basis. The boiler is serviced annually, April 2006. St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 24 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 3 2 4 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 4 33 4 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 3 3 3 3 3 3 3 4 St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 All written care records are regarded as legal documents and as such should be legible, unalterable, non judgemental, factual, have no abbreviations and be dated and signed. Some older care records have pencilled in reviews. These should be overwritten before archiving or when reviewed in full. This will prevent the entries fading or being erased. One bedroom floor covering and one toilet were malodorous. Attention to a review of the floor covering and odour control is recommended. As rooms are redecorated or upgraded the safety of hot surfaces should be individually re-appraised, with covers or cool surface type being considered. YA30 2 3 YA34 St Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Brigas DS0000008090.V317493.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!