Inspection on 23/11/06 for The Briars

This inspection was carried out on 23rd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

The Briars 06/12/05

The Briars 23/06/05

The Briars 04/11/04

The Briars 21/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

Langdale Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Briars,The The Broadway Sandown Isle Of Wight PO36 9BD Lead Inspector Liz Normanton Unannounced Inspection 23rd November 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Briars,The DS0000012466.V311636.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briars,The Address The Broadway Sandown Isle Of Wight PO36 9BD 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) 01983 403777 01983 407422 Greensleeves Homes Trust Mrs Fiona O`Regan Care Home 33 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (2) Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Room 4 on Level 2 is designated for use as respite care and may not be used for a long-term admission, due to its proximity to a fire escape. 6th December 2005 Date of last inspection Brief Description of the Service: The Briars is a home providing care and accommodation for up to 33 older people. Mrs Fiona Regan manages the home on behalf of the proprietors, Greensleeves Homes Trust. It is a large detached property located on a prominent corner site in the coastal town of Sandown. The home has, in recent times, completed a major building and refurbishment programme, which has created a range of new facilities including residents’ rooms and additional communal facilities. The grounds to the front of the property have also been landscaped and the new paths provide wheelchair access to a summerhouse. The addition of a conservatory has provided additional communal space for residents. All rooms in the home have en-suite facilities and are for single occupancy. They are accessible via a passenger lift or stair lift to all floors. Currently one room is designated for respite care. Weekly Fees from: £355.11 - £465.00. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 22/11/06 and focussed on what the commission considers to be core standards for a care home for older people as defined in the Department of Health (DOH) National Minimum Standards. The information in this report has been collected from a variety of sources, which includes a pre-inspection questionnaire completed by the manager, three resident’s feedback questionnaires a visit to the home, discussion with several residents, deputy manager, one senior carer two staff and four relatives. Four residents’ care files and three staff files were audited. The overall outcome was that the majority of residents are more then satisfied with the service with a very small proportion having issues. There were no requirements made at this inspection. What the service does well: Prospective residents and their representatives are provided with the homes information pack, which contains all the information required by regulation and more. Each resident is provided with a contract of the terms and conditions of the home. The home will not admit any prospective residents until they are satisfied that the individuals needs, can be met. All residents have a comprehensive care plan, which is reviewed monthly. The health and welfare of the residents is paramount and everybody has access to health provision and support. There is a wide range of activities to provide social interaction and mental stimulation for the residents. Residents are encouraged to maintain their independence and make choices on how they wish to live. The food is of a high quality and residents are offered alternative choices. Residents are protected from harm and the home has a robust effective complaints procedure. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 6 The home provides the residents with a homely environment with comfortable well - decorated surroundings. Each, resident is provided with their own room which is fitted with an en-suite and they are able to personalise the room to their taste. The staff team are well trained with over half having completed qualifications in care. The home is well managed and administered by a competent experienced qualified manager. What has improved since the last inspection? What they could do better: 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. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: In discussion with the deputy manager they reported that the home has an information pack, which is provided to prospective residents and there representatives. In discussion with two individual relatives prior to the inspection visit they confirmed that they had received written information about the home, which enabled them to make an informed choice. In discussion with a senior member of staff they reported that prospective residents are welcome to visit the home on several occasions prior to admission to enable them to decide whether the home will be suitable to them. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 9 The inspector viewed four resident’s files at random and found them to contain signed contracts. In discussion with four individual relatives prior to the inspection visit they confirmed that there parent had received a contract. Written feedback from one resident confirmed that they had been given a contract. In discussion with a senior member of staff they reported that the homes manager is responsible for admissions and visits prospective residents at home or hospital and undertakes a needs assessment. Information is also gathered from the care manager on referrals made by social services. In emergency situations the assessment will be completed within 48hrs of a person being admitted. The senior member of staff stated that the manager discusses prospective residents care needs with the senior staff team to ensure that the home can meet an individuals needs. Four residents files were viewed and contained comprehensive needs assessments, which covered all aspects of an individuals care needs. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 & 10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are generally upheld but there is room for improvement in this area. EVIDENCE: Deputy manager responsible for medication procedures. In discussion with a senior staff member they reported that the deputy manager and senior staff are responsible for drawing up individuals care plans in consultation with residents and using information gathered in the needs assessment. The inspector viewed four residents care plans and found them to contain detailed information on how a person needs and prefers to be cared for. The information on care plans included information supplied at the needs assessment. Care plans are reviewed monthly or as required and are dated and signed by staff, residents who are able will sign to confirm that they have been involved in the care plans review. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 11 The home undertakes risk assessments prior to admission as part of the needs assessment and these are added to if an incident occurs and the home tried to minimise potential risks to each individual in their care. In discussion with a senior member of staff they reported that residents are registered at the Sandown & Brading medical centres and that an allocated doctor visits the home once a week. The home will also call residents GPs as required who will visit residents in the home in the privacy of their own room. A chiropodist visits the home every eight weeks and the senior member of staff reported that the chiropodist usually attends to two patients at a time in the small conservatory at the front of the home. The small conservatory is on view to all visitors to the home and therefore treatment might be observed which compromises peoples rights to privacy and dignity. This matter was raised with the deputy manager who agreed to rectify the situation. In discussion with the senior member of staff they reported that one resident is receiving palliative care. The home have made provision of an airflow mattress and pressure cushion, to try to prevent pressure sores. The care staff are responsible for the day-to-day welfare of this resident. District Nurses visit the home as often as required to support resident’s health needs. Residents are able to stay with their own dental practice and opticians and are supported to attend visits by the staff. A number of resident’s attend Lake Clinic for dental and optical care. Those residents with hearing loss purchase their own hearing aids or are provided hearing aids by the NHS. The home supports one resident to attend a Warfrin Clinic. Greensleeves Homes trust have provided the home with a policy and procedures for the handling of medication, safe storage, administration, returns, non- prescribed drugs, (PRN). The deputy manager is responsible for medication practices within the home. In discussion with the deputy manager they explained that medication is delivered monthly directly from the Pharmacy. Medication is booked in to the home using the medication administration record (MAR) sheets. Staff who administer medication sign the MAR sheets to confirm that it has been given. Several MAR sheets were viewed and there was evidence that staff record that medication has been given, there was one omission of a signature on the sheets which was down to human error and the deputy explained that this matter would be raised with the member of staff responsible in supervision. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 12 Those staff responsible for the administration of medication have completed BTEC training in medication administration. Those staff that are trained in house have to follow a thorough induction process, which includes a medication induction booklet, shadowing a member of staff to observe procedures, supervision staff are not able to administer medication until the deputy manager is confident in their competency. Medication is stored securely within the home. Skin preparations and oral and optical preparations are stored separately. Each resident had a separate procedure for the administering of PRN’s attached to the MAR sheets. In discussion with several residents they confirmed that they always received their medication on time. It was observed that secondary dispensing was being practiced at the home with one member of staff potting up medications, which were then given out by another member of staff. The deputy manager was informed that this is an example of poor practice and does not meet medication administration guidelines. The deputy agreed to stop this procedure. In discussion with the deputy the reported that one resident is responsible for administering their own medication. The home has undertaken a riskassessment and consider the person capable of self-administration. The home have provided a lockable storage facility and sharps bin to this resident and it has been agreed between both parties that the deputy will monitor the situation monthly. In private discussion with one resident the inspector noted that a member of staff entered the room without knocking. The deputy was overheard to reprimand the member of staff who replied, “what’s the point of knocking? they never answer anyway”. This incident was raised with the deputy who reported that the member of staff will be spoken to about their attitude. Interaction between staff and residents was generally observed to be very positive with staff treating residents with dignity and respect. One resident stated that she likes to have a laugh with the staff and enjoys a bit of friendly banter. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose their lifestyle, social activities and keep in contact with family and friends. The social, cultural and recreational activities provided meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: The home offers a wide range of activities to for residents to choose from which include flower arranging, informative talks, bingo, hoopla, dice, knitting, ludo, snakes & ladders, guitarist, coffee mornings, painting, knitting, quizzes, church services. Residents are encouraged to participate in communal activities to enable them to develop new friendships and build up camaraderie. On the afternoon of the inspection visit several residents, were observed to be having a hand massage. In discussion with the deputy manager they reported that residents had the opportunity to celebrate Halloween as the home had a party and that Father Christmas visits the home on Christmas day. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 14 There was photographic evidence of outside entertainers performing in the home which included dancers and singers and a visit from a donkey which belongs to an ex-member of staff. The home publishes a quarterly newsletter which gives details of what activities have been provided. The home is actively trying to raise money for a mini-bus. Residents are encouraged to maintain contact with their family members and friends and visitors are made welcome at the home. Several people were observed visiting the home during the inspection visit. Residents who are able can come and go from the home as they please, others are supported to go out by family and friends and as mentioned earlier the home is aiming to purchase a mini-bus which will hopefully enable more people to get out and about. In discussion with the senior member of staff they reported that residents are able to make choices about many areas of their life which included waking and retiring, clothing, meals, activities, etc (this list is not exhaustive). Throughout the inspection visit resident’s were observed making choices in all aspects of their daily lives. One resident was observed exercising their right to smoke. The home has a no smoking policy but facilitates the resident to smoke outside. The homes policy is not to keep any residents monies and a billing system is in place. Wall safes are available in all bedrooms for the safekeeping of resident’s individual monies for them to manage. Breakfast is usually served in resident’s bedrooms but the dining room is open for those who prefer not to take breakfast in their rooms. Breakfast is usually a choice of cereal, toast with a variety of spreads Lunch is served in the dining room, however those residents who prefer can take their meals in their rooms. Those residents requiring assistance with eating were observed to be seated in a quite annexe area just off the lounge to afford them privacy and dignity. The home offers a set menu at both launch and suppertime (tea) but alternatives are available if residents do not like what is on the menu. A member of staff was observed informing residents what was for lunch and asking them what they would like, in talking with the senior member of staff they confirmed that this is done on a daily basis. All meals at the home are planned taking in to consideration resident’s likes and dislikes. The home uses a combination of fresh, frozen and tinned vegetables and provides wholesome nutritional meals for residents. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 15 Only one resident spoken with was dissatisfied with the meals provided at the home and this was mainly down to personal taste and being very particular in what they would eat. This person was more then capable of complaining and the deputy confirmed that this resident had exercised her right to complain on several occasions in relation to food. The home are trying there up most to meet this residents requirements. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: The home has a complaints policy and procedures information of which is available to residents in the homes information pack. There was evidence that residents exercise their right to complain and all complaints are logged. The home takes resident complaints seriously and acts upon them to try to rectify matters within a 28day timescale. There is an on going complaint for a resident who wishes to be on the same floor as their partner unfortunately this matter can not be rectified until a room becomes vacant. Written feedback from one resident and two relatives confirmed that they knew how to make a complaint but had not ever made one as they were very satisfied with the service. The home has an adult protection policy and procedure which is line with the Isle of Wight Adult Protection guidelines. Two staff spoken with confirmed that they had received adult protection training and were aware of the home’s “whistle-blowing procedure”. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 17 The home contacts social services adult protection team with regards to altercations between residents under the adult protection procedures and notify CSCI by sending a completed regulation 37 form. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A partial tour of the home was undertaken which included all communal areas, several resident’s bedrooms and the gardens. The home is well laid out and is easily accessible, safe and well maintained. It is decorated and furnished to a very high standard throughout. Written feedback from two relatives and in conversation with several residents they reported that the home is always kept clean. There is a facility available to residents for tea and coffee making in the small conservatory. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 19 The gardens were generally very pleasant and kept in good condition. In one area of the gardens there was some old furniture stacked up and this looked unsightly. In discussion with the deputy they explained that arrangements had been made for the furniture to be picked up for disposal and therefore it had been taken out of the storage shed for preparation. There has been a change to the layout of the ground floor communal areas since the last inspection with the lounge becoming the dining room and visa versa. This has improved the quality of service as the dining room is now nearer to the kitchen. A number of bedrooms on the ground floor have been fitted with overhead tracking to enable staff provide safer transfers for those residents with poor mobility. In discussion with one member of staff they reported that they had not been informed of the change and was very disorientated when they came on duty and would have preferred it if the senior management could advise staff of planned changes as it affects them and the residents. The home has a routine maintenance and renewal programme and employs two maintenance persons. The building complies with the requirements of the local fire service. In discussion with the deputy they reported that every door in to the home is fitted with a security camera for security purposes only. Security alarms are fitted to ground floor external doors, which alerts the staff of the doors opening. The home is also in the process in purchasing CCTV for coverage of the front door and its hallway. The laundry is situated away from food preparation areas and there is also a separate sluice room. There is a hand wash-basin fitted in the sluice room. Washing machines have the specified programming to meet disinfection standards. Staff are provided with protective wear and were observed wearing this in the course of their duties. One member of staff who was preparing sandwiches was not wearing an apron when asked why not she explained that she had forgotten and put one on immediately. The home has an infection control policy and procedures and all staff are training in infection control. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and employed in sufficient numbers to fill the aims of the home and meet the changing needs of residents. EVIDENCE: The home employs up to fifty staff. The senior staff team is made up of the registered manager, deputy manager and four seniors. Several ancillary workers support carers, which includes, cooks, housekeeper, maintenance personnel, cleaners and an activities co-ordinator. The staff rosters are planned to ensure that there are, sufficient staff on duty at all times to meet the needs of residents. In written feedback from 3 residents and discussion with several more at the time of the inspection visit the majority reported that they are well cared for and have their needs met. Two residents stated that they did not think the home employed sufficient staff, as they were always so busy. In discussion with two members of staff they felt that there was sufficient staff on the floor to meet residents needs however one felt that on occasions if staff had to take residents out to an appointment that this put pressure on the Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 21 remaining staff on duty. This was discussed with the deputy manager who explained that the senior staff are always available to come on to the floor to support the carers. Details sent to CSCI in the pre-inspection questionnaire indicated that 55 of the carers have completed National Vocational Qualification (NVQ) training at Level 2 or above. The inspector viewed three staff files of the most recently employed staff and these contained all the relevant documentation as required and evidenced that the home operates robust recruitment procedures. Greensleeves Home Trust has a training and development policy and the manager is committed to implementing this and developing the staff team and had produced a 2006 training action plan. Mandatory training includes health & safety, manual handling, fire training, basic first aid, basic food hygiene, infection control. Additional training includes medication training, risk- assessment, challenging behaviour, adult protection, dementia awareness, depression/Parkinson’s, diabetes awareness, deaf awareness, sight awareness, falls reduction and bereavement counselling. A number of training certificates are on display in the home next to the office. All new staff receive induction training within the first six weeks of their employment. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The manager has the experience and qualifications to manage the home. The management of the home is based on openness and respect. The home has quality assurance systems in place to ensure continued development of the service based on the needs of the residents. EVIDENCE: The registered manager was not available at the time of the unannounced inspection visit however in discussion with the deputy manager they reported that the manager had worked at the home for seventeen years and has completed the NVQ level 4 and registered managers award (RMA). The manager and other senior staff are familiar with the conditions and diseases of old age and are able to cascade this information down to carers. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 23 The registered manager is not responsible for running any other establishment. There are clear lines of accountability within the home with a defined senior management team and staff have regular supervision and annual appraisals. Those residents consulted thought highly of the manager and all said if they had a complaint that they would go to her in the first instance. The home has an annual development plan and in discussion with the deputy they reported that the home is considering expansion in the future with the addition of several bedrooms. Greensleeves Homes Trust have developed audit questionnaires for residents, stakeholders and relatives and friends. Information provided in the returns are looked at buy the manager and changes are made were possible. The deputy was not able to locate the feedback report at the inspection visit. In discussion with the deputy they reported that the home had tried to introduce residents meetings but that there had been very little interest from the residents so the meetings have been stopped. The homes policies and procedures are regularly reviewed and updated in light of changing legislation and of good practice recommendations. The home has a policy that no residents monies are held in safe –keeping as mentioned earlier in the report residents are encouraged to maintain their own finances and wall safes are available in all bedrooms. Those residents with poor capacity are supported through power of attorney or by relatives and solicitors. All expenditure made on behalf of residents by the home is billed for later payment. The registered manager ensures so far as is reasonably practicable the health, safety, and welfare of residents and staff. There was evidence of weekly fire alarm tests are undertaken and a record is kept. The manager has undertaken generic risk-assessment of potential hazards in the home . The registered manager complies with relevant legislation in relation to the management of a residential care home. Electrical appliances are serviced annually and records are kept that of PAT tests . Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 24 There was evidence provided that the home has had a periodic inspection report for an electrical wiring installation. A gas safety certificate was viewed. A letter seen from the environmental health department confirmed that at a recent visit the homes operations were found to be satisfactory and comply with food safety legislation. The home displays an Employers Liability insurance certificate. There was evidence that lifting equipment is serviced regularly. The home regularly reports accidents and incidents to CSCI with over 44 falls recorded since the last inspection. In discussion with the deputy they reported that they are over cautious and will report all incidents at the home. There was evidence that every effort is made to try to prevent falls within the home. Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 4 Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Refer to Standard Good Practice Recommendations Briars,The DS0000012466.V311636.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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