Inspection on 14/02/05 for The Branksome Park

Care Home For Older PeopleBranksome Park (The)17 Mornish Road Branksome Park Poole Dorset BH13 7BYUnannounced Inspection14th February 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment The Branksome Park Address 17 Mornish Road, Branksome Park, Poole, Dorset, BH13 7BY Email address Name of registered provider(s)/company (if applicable) Mr A Tredrea Mrs C Tredrea Name of registered manager (if applicable) Mrs Clare Elizabeth Tredrea Type of registration Care Home No. of places registered (if applicable) 34 Tel No: 01202 761449 Fax No: 01202 768071Category(ies) of registration, with (number of places) Old age, not falling within any other category (34) Registration number D550002057 Date first registered 19th December 1997 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 26th August 2004 YES YES 14/06/04 If Yes refer to Part CBranksome Park (The)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th February 2005 09.15 am Jo PalmerID Code072704Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionClare Tredrea ­ Registered provider/managerBranksome Park (The)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementBranksome Park (The)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of The Branksome Park. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Branksome Park (The)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Branksome Park Nursing Home is a large Edwardian house, which has been extended over the years. A planning application has been approved byte h local authority for the premises to be extended although this had been resubmitted for further consideration of additional works. Mr & Mrs Tredrea hope the building works will start in the spring of 2005. The home is set in a residential area of Branksome Park in its own mature gardens, which are accessible to the service users from the lounges and some of the bedrooms. There are eighteen single and eight double rooms. Branksome Park Nursing Home is a care home registered to accommodate a maximum of 34 service users in the category OP (older persons) although generally keeps occupancy at 32. There is a condition placed on the registration allowing the home to accommodate a maximum of five persons between the ages of 55 and 65 years for nursing care. Branksome Park Nursing Home provides general nursing care for a variety of conditions and also short term respite care and convalescent care. The home has been owned by Mr and Mrs Treadrea since 1997, Mrs Tredrea is also the registered manager.Branksome Park (The)Page 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection took place on 14th February 2005 lasting for three hours. Mrs Tredrea, registered provider and manager was present throughout. This inspection concentrated on some of the National Minimum Standards and requirements of the last inspection; not all standards were assessed during this visit, and the reader is referred to previous inspection reports which can be obtained from the home, or by phoning 0870 2407535, or on the web site at www.csci.org.uk In this report, service users are referred to as residents. Three residents and two relatives were spoken with during this inspection, all were satisfied with the level of services and facilities provided. Choice of Home (Standards 1-6) Two of these standards were assessed and had been met. Prospective residents and their relatives have the information they need to make an informed choice about whether to move to Branksome Park Nursing Home. Information in the form of a Service User Guide containing the homes Statement of Purpose is available to all residents and their relatives. Residents and relatives spoken with confirmed that they had sufficient information. It was evident that assessments of residents needs are carried out prior to admission to ensure the home is able to meet their needs. Health and Personal Care (Standards 7-11) Three of these five standards were assessed and had been met Care plans and records of care provided demonstrate that residents health, personal and social care needs are set out in an individual plan of care. Care plans provide basic instruction to staff in relation to meeting personal and nursing care needs. This inspection evidenced that residents are treated with respect and due regard for their dignity. Records examined evidenced that residents have access to health care services to meet assessed need including GPs and residents spoken with confirmed that appointments are made as required. Residents are protected by the homes procedures for managing medication.Branksome Park (The)Page 6 Daily Life and Social Activities (Standards 12-15) Two of these four standards were assessed and met. Residents and relatives spoken with confirmed that visiting arrangements are open and flexible with no restrictions. Relatives confirmed that they are made to feel welcome and are provided with relevant information concerning their relatives care. Residents also confirmed that the provision of food in the home was good, Mrs Tredrea is commended for carrying out an audit to identify availability of choices for residents, the audit results show that a high provision of alternative meals to the main menu are available. The menu shows three choices of main meal as well as their being a range of alternatives. Complaints and Protection (Standards 16-18) Two of these three standards were assessed and met. The home has appropriate policies relating to adult protection issues and complaints; residents have access to the complaints procedure through information provided in the Service User Guide. Staff training at induction and foundation level increases staff awareness of adult protection issues and correct courses of action if any such incidents are suspected or reported. There have been no reported incidents or complaints. Environment (Standards 19-26) Just one of these eight standards was assessed and met. This inspection did not intend to concentrate on environmental standards. One standard regarding protection of residents from accidental scalding from hot water and exposed pipework was examined and found to have been addressed. Previous inspections have not raised concerns about the standards of accommodation provided. Mr & Mrs Tredrea have obtained planning permission for substantial extension and refurbishment of the home; building works are due to commence in the spring. Once completed, the premises will be subject to inspection by the Commission before registration for the new build is approved. Mrs Tredrea has ensured that residents are fully aware of the proposed changes and a resident and relative consultative committee has been formed. Staffing (Standards 27-30) Three of these standards were assessed, two were met. Recorded evidence indicated that safe recruitment practices are used; all staff are employed following routine checks regarding their suitability. Staff are trained and competent to do their jobs, training programmes to induction and foundation standard are in place in accordance with recommended guidance and Branksome Park Nursing Home is commended for the way in which staff are assessed against these programmes. Numbers of staff are sufficient for the number of residents accommodated, however, the guidance given to the Commission on staffing levels, including numbers of trained nursing staff is that numbers and skill mix must be based on those prescribed by the previous registering authority. This and previous inspections have noted that at the weekends particularly, numbers of trained staff fall below that which is required. Whilst the inspector appreciates the difficulty in recruiting good calibre nursing staff to work in the care home industry, Mrs Tredrea is advised to consider this standard in her response to this inspection. Mrs Tredreas action plan must identify how this requirement is to be addressed, or, be able to demonstrate how, if at all, the nursing care needs of residents are reduced at weekends demonstrating the rationale behind a reduced number of trained nursing staff.Branksome Park (The)Page 7 Management and Administration (Standards 31-38) Three of these eight standards were assessed and met. Records examined demonstrated that residents rights and best interests are safeguarded with regard to confidentiality and records examined were up to date and accurate. Residents financial interests are safeguarded with good systems in place for the management and control of residents personal allowances where appropriate.Branksome Park (The)Page 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 18 OP27 The staffing notice issued by the Area Health authority must be adhered to. There must be 2 31.08.04 registered nurses on duty at all times between the hours of 8.00am and 8.00pm.Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). See Part CMet (Yes / No) YESBranksome Park (The)Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The staffing notice issued by the Area Health authority must be adhered to. There must be 2 registered nurses on duty at all times between the hours of 8.00am and 8.00pm. 1 18 OP27 This requirement was made at the last inspection dated 14.06.04 and is repeated for the second time. This inspection found the staffing notice to be met from Monday to Friday but not at the weekends 30.04.05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Branksome Park (The)Page 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NA YES NO YES NO YES YES NO NO NO YES NO YES 3 2 0 YES YES YES YES X X 14/02/05 09:15 3.0Branksome Park (The)Page 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Branksome Park (The)Page 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/EvidenceNO Standard met? 3The homes Statement of Purpose and Service User Guide were not examined during this visit, the last inspection reported that all necessary information is available to residents and their relatives, relatives spoken with during this visit confirmed that they had all the necessary information to assist them in making a decision regarding Branksome Park Nursing Home.Branksome Park (The)Page 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met?Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? On the care file examined for a resident admitted to Branksome Park Nursing Home in October 2003, a pre-admission assessment had been carried out a week prior to admission. The assessment showed that all aspects of the persons health and welfare had been considered. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met?Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met?Branksome Park (The)Page 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Care plans are held for each resident, care plans are produced for each area of assessed need and are cross referenced, for instance, on one file examined the care plan for meeting the persons mobility needs referred to the care plan for pressure relief and nutrition. Care plans demonstrate good basic level of instruction for staff to follow in order that assessed needs can be met including personal and nursing care needs. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence X X Standard met? 3Care documentation evidenced that residents have access to health care professionals including GPs and specialist nurses. Residents spoken with confirmed that appointments are made on their behalf as necessary if they require medical attention, a dentist, optician etc. One GP spoken with in relation to the care and attention received by one resident confirmed that nursing and personal care routines undertaken by the home were satisfactory for this resident and that as a practice, the GPs had no concerns with the care provided by Branksome Park Nursing HomeBranksome Park (The)Page 16 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? Medication management procedures in the home are satisfactory. Records examined detail all medication received into the home, that which is administered on behalf of residents and that which is disposed of when no longer required. Any medication not given at the prescribed time is accounted for and variable doses are recorded where given. There is satisfactory secure medication storage. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met?Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met?Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Residents and relatives spoken with confirmed that visiting arrangements were flexible and that they were able to receive visitors at any time.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 18 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? A recommendation was made at the last inspection that the home ensures that residents are aware of alternative meals to the main menu. In response to this, Mrs Tredrea is commended for carrying out an audit of meal provision carefully analysing meal provision and the alternatives taken by residents in order that meal provision can be reviewed and evaluated. The audit shows by means of graphs and charts, the percentage take up of alternatives to the main meals and the number of alternatives available each day and demonstrates that residents are able to choose from a selection of meal options. The menu has been reviewed and shows that there is a choice between three set meals on the menu and if these are not wanted, between 8 and 18 alternative dishes can be prepared (there are less alternatives available at the weekends) Residents spoken with confirmed that the provision of meals was good and a relative commented that the food always looks appetising, event the pureed diet which is well presented and enjoyed by the resident.Branksome Park (The)Page 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 0 X X X X 3 X 3Standard met?The homes complaints procedure is available to residents and other interested parties in the homes Statement of Purpose and Service User Guide. No complaints have been received by the home. The Commission for Social Care Inspection have received three complaints in the last year, which were referred to the provider, Mrs Tredrea for action. None of the complaints were upheld; the commission was satisfied that the complaints had been appropriately resolved. The three complaints received were in March, May and June 2004, no further complaints have been received.Branksome Park (The)Page 20 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met?Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES 0 3Branksome Park Nursing Home has appropriate procedural guidance available for staff in accordance with local authority policy `No Secrets concerning adult protection. No incidents have been reported.Branksome Park (The)Page 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met?Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 9 Key findings/Evidence Standard met?Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 22 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 23 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence NO NO YES X X X X Standard met? 0 X XX X X XBranksome Park (The)Page 24 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met?Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? A recommendation of the last report has been addressed, Mrs Tredrea confirmed that all radiators and exposed pipe-work have been guarded to prevent accidental scalding. Thermostatic control valves have been fitted to all baths and showers and some basins, on those basins where hot water is not regulated, Mrs Tredrea confirmed that risk assessments have been carried out as appropriate. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 25 StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 2Rotas examined showed which staff are on duty. Shifts are worked between 7.00am and 1.00pm, 1.00pm and 7.00pm and a 12 hour night shift from 7.00pm until 7.00am. Rotas showed two trained members of staff on duty for day time shifts from Monday to Friday and one trained member of staff at weekends. There are five health care assistants in the mornings, four in the afternoons and three at night. These numbers of staff are in accordance with the previous registering authority (Dorset Health Authority) guidelines except for the weekends where there is one trained nurse and the health authority specifies two. Branksome Park (The) Page 26 A separate rota shows the hours worked by Mrs Tredrea and Nurse Tempest, head of care, that demonstrates that between Monday and Friday, there are sometimes three trained nurses on duty. A rota of hours worked by ancillary staff is available showing that domestic staff, chef and kitchen staff are available. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Staff files were examined for two recently employed members of staff. Each file contained relevant documentation evidencing their fitness for employment including references, health questionnaires, information concerning previous employment, experience and qualifications, Criminal Records Bureau and POVA* checks. *POVA - Protection of vulnerable Adults (A list held by the secretary of state of persons considered unsuitable to work with vulnerable people)Branksome Park (The)Page 27 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? Branksome Park Nursing Home has developed a training package for new staff that involve a six week induction period and a six month foundation period from the date of employment. The training programmes were seen and noted to be organised around the occupational standards specifications. Mrs Tredrea confirmed that two new staff are currently undertaking the training at foundation level, works books seen include case studies and questions. Staff are supervised during their training by Sarah Tempest, Head of Care and marked workbooks demonstrated a thorough assessment of the staff members understanding of care practices and the principles of care.Branksome Park (The)Page 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Mrs Tredrea has demonstrated through management of the home and through the inspection process that she is competent and able to run the home.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met?Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 29 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met?Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 3 X X XBranksome Park Nursing Home manages some `petty cash on behalf of two residents at their request. The registered persons do not cash any pensions on behalf of residents. Records relating to management of the two sets of funds held demonstrate accurate recording of income, expenses and balances held. Recorded balances were accurate as cash amounts were counted. All money is held securely in the home and is only accessible to authorised persons. Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 30 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records seen were well maintained and accurate.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met?Branksome Park (The)Page 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSYES Condition Compliance Up to five service users between the ages of 55 and 65 years can be accommodated to receive nursing care. Comments Four service users between the ages of 55 and 65 years were accommodated at the time of inspection (14th February 2005)Condition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager Date Public reportsJo PalmerSignature Signature SignatureJo PalmerIt should be noted that all CSCI inspection reports are public documents. Branksome Park (The) Page 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 14th February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBranksome Park (The)Page 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 5th April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNOYESOther: enter details here Branksome Park (The)Page 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 We ........................... of .............................. confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 We ........................... of .............................. are unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Branksome Park (The)Page 35 Branksome Park (The) / 14th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000020431.V195246.R01© This report may only be used in its entirety. 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