Inspection on 20/06/07 for The Brambles

This inspection was carried out on 20th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Brambles 19/11/07

The Brambles 05/12/06

The Brambles 12/01/06

The Brambles 06/07/05

The Brambles 07/03/05

The Brambles 10/12/04

The Brambles 13/02/04

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 The Brambles 104 Station Road Soham Cambridgeshire CB7 5DZ Lead Inspector Elaine Boismier Key Unannounced Inspection 20th June 2007 10:15 The Brambles DS0000015227.V334491.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 The Brambles DS0000015227.V334491.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. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Brambles Address 104 Station Road Soham Cambridgeshire CB7 5DZ 01353 722971 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 Anthony Eric Barnes Mr Anthony Eric Barnes Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user over 65 years of age with learning disabilities (LD(E)) for the duration of their residency 5th December 2006 Date of last inspection Brief Description of the Service: The Brambles is a small home for three people with moderate to profound learning disabilities, and some physical disabilities. The home is a converted bungalow, and each service user has their own room, sharing communal accommodation, which includes a lounge/diner, kitchen bathroom and two WCs. Current fees are £900 per week with additional costs for chiropody and clothing. A copy of the inspection report is available at the home or via the CSCI website. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is report following a key inspection for The Brambles. The inspection was unannounced and was carried out by two Inspectors between 10:15 and 13:00 and took just under 3 hours to complete. Before the inspection 3 residents’ surveys were sent out and two of these were returned and had been completed by relatives on behalf of the people. Three relatives’/visitors’ surveys were sent out and two of these were returned. At the time of the inspection there were 3 people at the home and all of these were spoken to although not all of the people expressed their views to the Inspectors due to their complex communication difficulties. Staff, including the Manager, were spoken to also. A tour of the premises was made and documentation was examined. People who live at the Brambles receive a good quality of care although due to poor care practices in medication and poor management of the home The Brambles has been assessed to be a poor performing service due to the risks posed to the health, welfare and safety of the residents. The Brambles could improve from such a poor quality rating to at least that of an adequate quality rating should action be taken to meet the requirements and any recommendations in this report. It is expected by us that should any improvement be made following this inspection, then these improvements be sustained without the reliance on regulatory activity by us, the Commission for Social Care Inspection. Recommendations made in previous inspections and repeated following this inspection do not appear in the recommendation table of the report although they have been referred to in the main body of this report. For the purpose of this report those living at the home are referred to as people or residents. What the service does well: The home is well integrated with the local community and residents have access to a range of activities. Links with families of residents is strong and the home operates on a “family” ethos given the small size of the home. One resident’s survey said, “ Family The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 6 and friends are always welcome to visit at any time and visits to my mother’s house are frequent.” Both relatives’/visitors’ comment cards said that the home welcomed them into the home at any time and that they could see the person who they were visiting in private. The Brambles provides a comfortable and clean home for residents to live in. Comments made in the surveys that we have received were positive such as, “ My family and myself were able to view the Brambles several times and speak to staff/residents. Questions to staff were answered reassuringly and professionally” and “Care and welfare is of a very high standard.” What has improved since the last inspection? What they could do better: A requirement was made for action to be taken by 31/10/05 for care plans to be reviewed at least every 6 months. This requirement was assessed as not met during the inspection of January and December 2006. This requirement has not been met and has been carried forward with a new timescale for action. Care plans must provide sufficient detail to provide staff the guidance in how to meet the assessed needs of the residents. A requirement has been carried forward with a new timescale for action. Care plans must be implemented when a person’s needs change. A requirement has been made about this. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 7 Decisions made by residents, or their representatives, must be recorded in the residents’ care records. A requirement has been carried forward with a new timescale for action. Records for the receipt of medication must be accurate. A requirement has been carried forward with a new timescale for action Medication must be stored safely. An immediate requirement was made about this at the time of the inspection. Medication records should be signed and dated should handwritten entries be made. A recommendation has been made about this. A recommendation was made for the temperature of the hot water accessed from the bath to be checked and recorded. This recommendation remains. A requirement has been made for staff to be trained to ensure that people receiving care are safe from harm. A recommendation was made about for existing methods of formal supervision of staff to be developed. Documentation was not available for inspection and as such this recommendation remains. A requirement was made for quality assurance systems to be developed. This requirement has been carried forward with a new timescale for action. A recommendation has been made for written policies and procedures that are appropriate to be implemented. A recommendation has been made for documentation to be made available in a format that would be appropriate for people living at the home to understand. Two requirements have been made for all staff to attend first aid training and fire training. A recommendation has been made for records for fire checks to be made clear to accurately record what has been checked. 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. The Brambles DS0000015227.V334491.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 The Brambles DS0000015227.V334491.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, 2 & 4 Quality in this outcome area is good. Prospective residents have a good standard of information about the home to assist them in their decision where to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made following the inspection in December 2006 for the Statement of Purpose to be updated, as there was no information about the age range and sex of residents that the home intended to provide accommodation and care for. The Statement of Purpose was seen and this had been amended to include the age range and sex of people that the home intends to care for. This requirement has been met. According to information provided by the Manager before the inspection there have been no new admissions to the home since the last inspection. Standard 2 relating to this area was met at the inspection of December 2006 and remains as such. Following the inspection in December 2006 we received a letter from the Manager and, as a result of this, a new certificate has been issued to show the correct registration details. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 10 Comments made from residents’ surveys included, “ My family and myself were able to view the Brambles several times and speak to staff/residents. Questions to staff were answered reassuringly and professionally.” The Brambles DS0000015227.V334491.R01.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 & 9 Quality in this outcome area is adequate. People are supported and consulted by staff in how they want to live although the standard of recording poses a risk to the health and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information provided in the care plan, that we saw, with regards to social care, was detailed and provided the reader good information about the person’s choices of how they wished to engage in social activities. A requirement was made following the inspection of 6th July 2005 and as this requirement was assessed as not met at the inspection of 12th January 2006 this requirement was carried forward with a new timescale of 31st March 2006. This requirement was related to the review of care plans. Evidence suggested that this requirement had not been met and was carried forward with a new timescale of 28th February 2007. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 12 Examination of a person’s care record indicated that this had been revised although the Manager reported that he had not enough time to complete the revision of the remaining two people’s care records. This requirement has been carried forward with a new timescale for action. A requirement was made following the inspection in December 2006 as the care records provided insufficient guidance for staff in how to meet the needs of the residents. Examination of the revised care plan indicated that there remained deficiencies in such guidance. For example there was no clear guidance for how to care for a resident with diabetes. A member of staff stated that there was no care plan for how to care for someone when they were experiencing a seizure. This requirement has been carried forward with a new timescale for action. According to the information provided by the Manager there are no documents available that would be appropriate for the people to try and understand with support from staff and relatives/friends. A recommendation has been made about this. Examination of a resident’s care records indicated that a doctor had visited this person. The Manager reported that no care plan had been implemented to provide staff guidance how to care for the person with a changed medical condition need. A requirement has been made about this. A requirement was made following the last inspection for decisions made by the people living at the home to be obtained and these decisions, based on assessed risk, to be recorded in the care plans. These decisions were with particular regard to the use of a restraining belt at all times whilst the person sat in their wheelchair. Examination of the person’s care records and discussion with the Manager indicated that no action had been taken in response to this requirement. This requirement has been carried forward with a new timescale for action. Both residents’/visitors’ comment cards confirmed that they, on behalf of the resident, were consulted about decisions and care of the resident. One person wrote, “ I am consulted always on my son’s health and well-being.” We saw people being cared for staff in an individual and flexible way taking into account their choices and preferences how they chose to live, for example what time they wanted to get up out of bed. Currently the home does not access advocacy services for people to be represented in an impartial way. A recommendation has been made about this. The Brambles DS0000015227.V334491.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 14,15 16 &17 Quality in this outcome area is excellent. People are provided with opportunities to live an excellent quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No person currently attends education or employment facilities due to their conditions. Standard 12 is therefore not applicable. We observed a member of staff taking a person out to the village of Soham. The Manager stated that arrangements had been made for other residents to go out into the community that day. Examination of a person’s care records indicated that they were provided with opportunities to go out to the local cafes and pub. Both staff and the Manager reported that one of the people had gone on holiday to the Cotswolds with the support of staff from the home. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 14 One resident’s survey said, “ Family and friends are always welcome to visit at any time and visits to my mother’s house are frequent.” Both relatives’/visitors’ comment cards said that the home welcomed them into the home at any time and that they could see the person who they were visiting, in private. A requirement was made for the preferred name (of how people wished to be called) to be recorded in the care records following discussion with the people. Examination of a person’s care records indicated that the person had been consulted about this and their preferred names were recorded in the care records. This requirement has been met. A recommendation was made at the last inspection for food to be presented in a more appealing way. The presentation of food at lunchtime was seen and this was noted to be of an acceptable standard. As a result of this, this recommendation has been considered. A resident said that they liked the lunch they were eating. Copies of menus were provided by the Manager before the inspection and these showed that people are offered personal preferences of food. The copies of the menus showed also that people are offered meals four times each day. The Brambles DS0000015227.V334491.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 & 20 Quality in this outcome area is poor. Although people receive appropriate care and support the standard of medication practices poses a risk to the health and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A relatives’/visitors’ comment card said, “ Care and welfare is of a very high standard.” Discussion with the staff and Manager indicated that residents were given the opportunity of how they wished to live including getting up and going to bed. This we also noted during the inspection and records confirmed that care was provided to people in a flexible way. Examination of a person’s care notes indicated that a doctor had seen the person. According to the Manager the local authority has reviewed all the residents in May 2007 and the home is waiting for these reports. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 16 A requirement was made following the inspection in December 2006 as medication was being administered in an unsafe way. Staff described to us how medication is administered and recorded for someone when they are out of the home. We consider on the basis of this evidence that this requirement has been met. A requirement was made for medication records to provide information of the quantity of medication received in the home. Although there were previous records that indicated the amount of medication that was received into the home, current medication records did not provide this information and was not in accordance with the home’s policies and procedures. The requirement made from the December 2006 inspection has been carried forward with a new timescale. Discussion with staff and examination of medication administration records indicated that these records were signed following administration of medication and no omissions of recording were noted. It was noted however that hand written entries of medication had no signatures or dates when the entries were made. A recommendation has been made for the signature of one person making the entry and a second signature of a witness to be recorded and this record should also include the date of the entry. Medication was kept in both unlocked and locked cupboards in the kitchen that is not locked. The medication that was kept in an unlocked cupboard was located above an oven. Staff reported that staff sometimes use this oven. There was no method of monitoring the air temperature of the cupboard or the kitchen. A requirement has been made about this. Prescribed medication was also found in a person’s bedroom that was not locked and also in glass tumblers on one of the kitchen surfaces. An immediate requirement was made at the time of the inspection. A requirement was made following the inspection of December 2006, as keys to the medication were kept in an unlocked drawer that was in an unlocked room. During this inspection medication keys were kept on the person and as such this requirement has been met. The Brambles DS0000015227.V334491.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 &23 Quality in this outcome area is good. People are listened to and are safe from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have received no complaints or allegations of abuse against the home. Information provided by the Manager before the inspection notes that the home has received no complaints or allegations of abuse. Both residents’ surveys indicated that the person, or person representing the resident knew who to speak to if the resident was unhappy and both residents’/visitors’ comment cards said that the person knew of the complaints procedure but had never made a complaint. Both completed residents’ surveys said that the person considered they were always treated well by care staff and this we observed to be the case during our inspection. The home manages two of the people’s personal allowances. The Manager keeps these monies in the office based at is own home that he was not able to gain access to at the time of the inspection. As a result of this we were unable to assess how people’s personal monies were being safeguarded by the home. The Brambles DS0000015227.V334491.R01.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 & 30 Quality in this outcome area is good. People live in a comfortable and clean home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We visited all the areas of the home and saw the well-kept gardens. The home provides a homely and clean place for people to live in. A recommendation was made for the home to check that hot water in the bath was always of a safe temperature. The Manager reported that he has made arrangements to start to check this although no checks had been carried out. Although the recommendation will not appear in the table for recommendations of this report this recommendation remains to be considered in full. Both residents’ surveys said that the home was always clean and fresh. Comments included, “ Excellent environment-no concerns.” The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. People receive care from staff who are kind and caring but need to be better trained to ensure the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We noted that staff were caring for people in a kind and considerate way. Information provided by the Manager before and during the inspection indicates that the home has 4 of the 7 members of staff who have an NVQ level 2 or equivalent qualification in care i.e.57 of care staff. From the inspection report of December 2006, “Examination of 2 staff files indicated that the majority of required information is obtained about staff before they work at the home. A photograph of a member of staff was not available. However the Commission has taken the reasonable view that the remaining required information was available and satisfactory about this person and, on this occasion, has not made a requirement. Nevertheless it is the Commission’s expectation that this shortfall is to be remedied by the Manager.” Discussion with the Manager indicated that this action had not taken place although he stated that he is making arrangements to address this shortfall. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 20 Information provided by the Manager before and during the inspection indicated that the home is actively recruiting staff. Evidence suggests that checks are being carried out before this person may start working at the home. Information provided by the Manager before and during the inspection the inspection indicated that arrangements are in place for NVQ level 2 training, infection control, first aid and food hygiene. Information provided by the Manager before the inspection notes that staff have attended training in moving and handling, administration of medication; adult abuse and epilepsy although during discussion with the Manager and staff some training has not been attended in over a year. It was noted that a member of staff responsible for administering medication had not received training in safe medication practices. Other staff indicated that training that they had attended was provided by another employer, rather than by The Brambles. A requirement has been made about this. A recommendation was made for existing methods of formal supervision of staff to be developed. We were unable to assess the progress in this area, as the documentation was not available for inspection. This recommendation will not appear again in the recommendation table of this report although we expect to assess this standard and what progress has been made at a future inspection of the home. We were unable to assess in full the standards associated with staff training and staff supervision, as the associated documentation was not available at the time of the inspection. The Manager reported during the inspection of December 2006 that he was making arrangements for such documentation to be kept at the home. It is our expectation that when we inspect the home again within the next 6 months that this documentation will be made readily available to us for inspection purposes. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 21 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): 37,39,40 & 42 Quality in this outcome area is poor. People live in a place that poses a risk to their health and safety due to poor management of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager before the inspection provided copies of duty rosters. Examination of information indicated that during a two-week period the Manager was rostered to have one day off per fortnight. When working he worked a range of day and night duty, sometimes without a break. For example the duty roster for 1st May showed that the Manager started work at 18:00 on 1st May and finished his duties on 2nd May at 20:00; a total of 26 hours being on duty. On 6th May 2006 the duty roster showed that the Manager worked from 22:00 on the 6th of May and completed his duty at 13:00 on the 7th May 2007: a total of 15 hours. On the 8th May the duty roster The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 22 showed that the Manager started work at 22:00 and finished his duty at 20:00 on the 9th May 2007; a total of 22 hours. This pattern of working was also recorded in the copy of the duty roster for the following week and during the inspection the manager reported that such working arrangements had been carried out since February 2007. At the inspection the Manager described the work that he carries out when he is on duty including nighttime. Staff work at night on a “sleep-in” basis. However the Manager reported that during most nights residents require assistance and therefore staff have a disturbed night’s sleep. We expressed our concerns to the Manager with regards to the safety of residents being cared for by tired staff although the Manager considered that he did not share our concerns. The number and type of requirements and recommendations made in this report and the report of December 2006 might be considered reflective of the standard of the management of the home. A requirement had been carried forward from 30th March 2005 and a new timescale was made for 5th April 2007, as there were no effective, formal quality assurance systems in place. It was clear, during this inspection, that there has been no action taken by the Manager to meet this requirement. This requirement has been carried forward and a new timescale for action has been made. This requirement includes information about quality assurance systems that have been adopted by the home, to be submitted to us by 30th September 2007. Information provided by the Manager before the inspection notes that some but not all policies and procedures have been reviewed as part of a quality assurance. Policies not available, and might be considered appropriate, were discussed with the Manager at the time of the inspection. A recommendation has been made about this. Information provided by the Manager before the inspection notes that 2 of the 7 current care staff hold a current certificate in first aid. A requirement has been made about this as there is lone staff working at the home. According to both staff and Manager there has been no fire training, including a fire drill, carried out within the last 6 months. A requirement has been made in relation to this. Records for fire checks were seen and these provided insufficient information to provide the reader what checks had been carried out. A recommendation has been made about this. The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 23 Fire checks that had been carried out had not been carried out between October 2006 and 21st March 2007. Records seen indicated that fire alarms had been serviced every 6 months. During the tour of the premises it was noted PAT tests had been carried out in May 2007. Records for temperatures of fridges and freezers were seen and these were satisfactory. The Brambles DS0000015227.V334491.R01.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 3 3 x 4 3 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 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 3 x LIFESTYLES Standard No Score 11 x 12 N/A 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 1 x 1 2 x 1 x The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2)(a) Requirement The care plans must be kept under review in accordance with the regulations to ensure that people are receiving the appropriate care. Requirement carried forward as timescales of 31/10/05, 31/03/06 & 28/02/06 not met. New timescale for action made. Timescale for action 30/09/07 2. YA6 14(2)(b) 3. YA6 15(1) Care plans must be implemented 01/08/07 to provide staff guidance in how to appropriately care for people who have a change of need. The care plan must provide 01/08/07 sufficient detail for staff guidance in how to provide appropriate care for people to reduce the risk of harm to their health, welfare and safety. Requirement carried forward as timescale of 15/01/07 not met. New timescale for action made. Decisions of people must be obtained and these decisions are recorded in the care plan to ensure that people are not being controlled. Requirement DS0000015227.V334491.R01.S.doc 4. YA7 12(3) 01/08/07 The Brambles Version 5.2 Page 26 carried forward as timescale of 15/01/07 not met. New timescale for action made. 5. YA20 13(2) & 17(1)(a) Records of the receipt of medication, including the quantity, must be accurate to provide an accurate audit trail to protect people from the risk of harm. Requirement carried forward as timescale of 13/12/06 not met. New timescale for action made. Medication must be stored safely and according to the manufacturer’s instructions. 14/07/07 6. YA20 13(2) 22/06/07 7. 8. YA35 YA39 18(1)(c) 24 Staff must be trained in 01/09/07 medication, infection control & food hygiene. Effective, formal quality 30/09/07 assurance systems must be in place to ensure that care provided is up to date, procedurally safe and reflects the wishes of the people living at the home. Information about the quality assurance systems to be submitted to the Commission. Requirement carried forward as previous timescales of 30/03/05 & 05/04/07 not met and new timescale for action made. All staff must be trained in first aid procedures to reduce the risk of harm to people’s health and safety. All staff must be trained in fire safety to reduce the risk of harm to people in the event of a fire. 01/08/07 9. YA42 13(4) 10. YA42 23(4)(d) 01/09/07 The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 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. Refer to Standard YA6 Good Practice Recommendations Documentation should be in a format that people might be able to understand. 2. YA20 Hand written records on medication sheets should include signatures of the person making the entry and the signature of a witness and the entry should include the date when this entry is made. Policies and procedures appropriate to the home should be developed and implemented with reference to Appendix 2 of the CHRS The record for fire checks should demonstrate what has been checked. 3. 4. YA40 YA42 The Brambles DS0000015227.V334491.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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