Care Home: Brackenley

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What the care home does well People living in the home said `it was homely`, `they were happy`, and they `liked living there.` The information kept about people is good and is the right kind of information needed; this helps staff support people properly all of the time. Staff believe it is important for people to make choices of their own. This helps them become more independent. The staff makes sure everyone at Brackenley has a happy and fulfilling lifestyle. What has improved since the last inspection? The person who owns the home has provided the Commission with the financial information it needs to be confident the home is being run in people best interests. What the care home could do better: The way the registered manager makes sure the staff have the right qualities to work with people living in the home must be improved. CARE HOME ADULTS 18-65 Brackenley 33 Forest Lane Head Harrogate North Yorkshire HG2 7TE Lead Inspector Caroline Long Unannounced Inspection 3rd January 2008 09:30 Brackenley DS0000007818.V352977.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 Brackenley DS0000007818.V352977.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. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brackenley Address 33 Forest Lane Head Harrogate North Yorkshire HG2 7TE 01423 862230 01423 861541 brackenley@btopenworld.com 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) Applewalk Homes Limited Mrs Julie Ann Lunn Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 12 Service Users with Learning Disabilities some or all of whom may have Physical Disability Service Users with physical disability not to be accomodated on the second floor 02/02/07 Date of last inspection Brief Description of the Service: Brackenley is a care home registered by Applewalk Homes Limited to provide personal care and accommodation to up to twelve adults with learning disabilities under the age of sixty-five years of age. The home consists of a large Victorian detached property. The home is situated between Harrogate and Knaresborough and has good access to all the facilities in both towns. All twelve bedrooms are single and are sited on several floors. Whilst the home has neither a usable passenger lift nor stair lift, all areas are accessible to those people currently living there. The home has level access. Current information about services provided at Brackenley in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection are available by contacting the home. Information provided by the manager on 07 January 2008 indicated that the current weekly fee for the home is from £740 per week. Additional costs include the provision of extra support by staff, toiletries, hairdressing, holidays, leisure activities and clothes. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This is what was used to write this report. • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called annual quality assessment questionnaire. Information from surveys that were sent to all the people who live at the home, relatives, health professionals and the staff. Nine people who live in the home and two relatives sent back their surveys. An unannounced visit to the home. This lasted over six hours and included talking to the staff and the registered manager about their work and the training they have completed. And checking some of the records, policies and procedures the home has to keep. Some time was spent talking with three people who live in the home. • • The inspection focused on the key standards and also matters, which were raised at the last inspection. What the service does well: What has improved since the last inspection? Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 6 The person who owns the home has provided the Commission with the financial information it needs to be confident the home is being run in people best interests. 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. The summary of this inspection report can be made available in other formats on request. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 7 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 Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 8 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): Standard 2. People who use this service experience good quality outcomes in this area. People will be assessed before admission to the home to make sure Brackenley is the right place for them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Although no one has moved into the home since 2004 the registered manger was able to fully explain how she would manage the process in a way which is user focused and would result in the best outcomes for the people already residing in the home and any new people moving in. For people moving into the home the registered manager explained when an admission occurs the care manager would carry out a referral and needs assessment. Following this a full assessment of their needs would be carried out by the registered manager, where they would meet with them and discuss their needs and aspirations, and gather together other information from any relatives or other agencies involved. Next, they would commence visiting the home and spend at least one night in Brackenley before they came to stay permanently. Throughout this process, staff would be sensitive to their and their relatives’ needs and the visits would occur at a pace set by them. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 9 Also, after a settling in period, a review would be held to confirm that they are happy with the arrangements, where the views of the people living in the home would be given careful consideration. A member of staff was also able to confirm that she could remember people visiting before moving in. The registered manager also explained they are currently going through the admission process with someone who is interested in moving into the home. Six people as part of their surveys said they were asked if they wanted to move into the home and they did recieve enough information before they moved in to Brackenley. The registered manager explained that most people living in the home no longer have a care manager, however the staff carry out a review of the care plan every six months where with the agreement of the person living in the home, relatives are invited to be present. Two relatives who returned surveys stated they always get enough information about the care home or agency to help them make decisions and felt the care home meets their relatives needs. One commented: ‘It was very valuable to attend my relative’s review and to have regular opportunities to discuss family contact, financial matters therapeutic and leisure activities.’ The statement of purpose was reviewed and contained all the information necessary. It is available in large print or by a taped booklet. The home produces an annual newsletter, which is also available to people who may consider moving into the home. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. People who use this service experience good quality outcomes in this area. Brackenley helps people to make decisions about their lives, with clear care plan instructions and risk assessments to maximise their safety. We have made this judgement using a range of evidence, including a visit to this service EVIDENCE: Three people who live at Brackenley said they were able to make choices about their lifestyles and their care. When talking with the inspector they said they were happy at Brackenley and described it as home. During the site visit, staff were observed encouraging people to make choices about their lives. Also eight surveys returned by people living in the home, the records, and the staff spoken with provided further evidence that people are making decisions and choices about their lives. Three peoples’ case records were looked at in order to check that a plan had been formulated which would help staff provide support to people according to their needs and wishes. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 11 Overall the information in the care plans was person centred, quite detailed with people personal preferences and choices. They promoted independence and provided people with the care they needed in the way they wanted. Where risks were identified, risk assessments were carried out which provided staff with the actions they needed to take to minimise any risk whilst promoting independence. Also in some instances guidance was available to manage specific behaviours. Evidence from the registered manager, staff and a person living in the home confirmed the reviews of peoples care are carried out regularly and relatives are involved. However at present these are not recorded. The registered manager agreed following the inspection staff will commence to record the reviews in the care plans. The annual quality assessment questionnaire states they have recruited a care plan co-ordinator. Two relatives stated the home supports people to live the life they choose One comment made was: ‘The care my relative receives is very much person centred. This means that they are often supported doing the things that really important to them on a one to one basis. They are supported by people they know who understand and respect them.’ The home has regular meetings where people living in the home can make their views known. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 12 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): Standards 12,13,15, 16 and 17. People who use the service experience good quality outcomes in this area. People are helped and supported by the staff to make choices about their lifestyle and develop their life skills; this results in them leading a full and active life. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service supports people to identify what they want to do and how they want to do it and then supports them to achieve this. This was evidenced by three people spoken with during the site visit who described a list of activities they carried out, which followed their social and religious interests, and educational activities of their choice. A relative also commented: ‘Support has been available for my relative to practice their faith and join in a full spectrum of appropriate activities.’ Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 13 Two people describe how living in the home had a ‘family atmosphere’, where they benefited from everyone ‘getting on’. People said they had been on holiday to America, Edinburgh, Disneyland Paris, the French Alps and Centre Parcs. Staff confirmed they were able to support people to carry out the activities or go on holiday when they choose. Their care records also confirmed this. The two relatives who returned their surveys stated they were always encouraged to keep in touch and that people had received the support necessary to meet their different needs. The records also confirmed that people are encouraged and helped to keep in touch with their relatives. Two people living in the home said they had been home over the Christmas period. A persons care records included the support they would need to help them to exercise their right to vote. However there was evidence from people and the residents meeting minutes that they were unhappy about the kitchen being locked, and having to go to their rooms at eleven pm. The registered manager explained these were both to promote peoples health and safety and they were explained in full to people living in the home both when they first moved in and during the residents meetings. Although people could ask staff to open the kitchen for them and could remain up in their rooms after eleven pm as long as they liked. Two staff and three people living in the home said they had a choice of food, and there was always enough. On the day of the site visit people were having sandwiches from the local take away service, they were given a menu to make a choice, and said they were enjoying them. There are two large dining tables in the main lounge area where people meet and talk and eat, staff and people living in the home were observed eating and talking together during the day. A yearly newsletter is produced with input from people living in the home and this is posted out to everyone involved with the people at Brackenley. The newsletter shows where people have been on holiday and some of their achievements during the year. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20. People who use the service experience good quality outcomes in this area. People can be confident that the health and personal care they receive is based on their individual needs. The principles of respect, dignity and privacy are followed. We have made this judgement using a range of evidence, including a visit to this service EVIDENCE: Looking at peoples plans of chare showed they promoted both sensitivity and respect and gave detailed descriptions of how the people preferred to be supported with personal care. Half of the staff are male, this enables people in the home to have their physical personal care needs carried out by a gender they feel most comfortable with. The registered manager explained how the people in the home generally went to the local GP. The records clearly evidenced that people in the home were given choices and made decisions about their health care. One person was being encouraged to go to the optician, a second person said they enable them Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 15 to access the health care they need and would give a ‘thumbs up’ about the help they were given. The medication looked at was kept in a locked cabinet and when dispensed recorded on a medicine administration record sheet. To reduce the risk of people receiving the wrong medication the home uses the normad system where medication is dispensed by the pharmacist into a box, with compartments for each time they have to be taken. The registered manager explained the boxes are renewed weekly, when she will carry out an audit to make sure everything is in order. She also confirmed anyone who administers medication is trained. Also the pharmacist carries on an audit on the medication annually. One person spoken to during the site visit confirmed that they are responsible for their own medication, which they keep in a locked drawer in their bedroom, which is also locked. The registered manager explained they take the medication from a nomad box and she had made sure there were no risks to the person before this was commenced. However this had not been recorded in the care records, to make sure everyone is always aware of any risks there may be when a person is self medicating the risk assessment should be recorded in the care records. The registered manager agreed to carry this out, she explained although an assessment had been made it was not the practice of the home to record this, especially when they did not believe the person was at any risk. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23. People who use the service experience good quality outcomes in this area. People are able to express their concerns and are safeguarded from harm. We have made this judgement using a range of evidence, including a visit to this service EVIDENCE: People living at Brackenley feel able to make their views known if they have any concerns or complaints. This was evidenced from the nine surveys returned all said they knew who to speak to if they were unhappy, and six knew how to make a complaint. Also during the site visit people were seen visiting the office to see the registered manager to make their views known. Two people spoken with during the site visit also said they would complain if they needed to. The home has a complaints box in the reception area. There has been one complaint since the last inspection, which was resolved by the registered manager. The complaints policy was reviewed in 2007 and includes how long a response will take. The home has a copy of the North Yorkshire Procedure for Safeguarding Adults and the No Secrets Policy. The homes policy for safeguarding adults was reviewed in 2007 and follows current guidelines. Discussion with the registered manager showed she was aware of the actions to take to safeguard adults. Staff had received training in adult protection and safeguarding issues either during induction or as part of their national Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 17 vocational qualifications and two spoken with were aware of whom to alert if an incident occurred. The registered manager explained that staff are made aware of how to ‘blow the whistle’ on bad practice. People are given the choice to manage their own finances. The registered manager explained they have their own bank accounts and keep some cash in the home in the office in a locked filing cabinet. Also, either independently or with help they account for their spending by recording the purchases on a sheet and keeping receipts. The registered manager was seen during the day giving people money and records looked at showed receipts are kept and the people living in the home are involved in signing the records. Brackenley DS0000007818.V352977.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): Standards 24 and 30. People who use the service experience good quality outcomes in this area. People live in a clean and comfortable home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is very ‘homely’ and comfortable and clean. home said this was normally the case. People living in the People said their rooms were clean, and comfortable, they liked them and they have been decorated and furnished to their personal interests and tastes. All the bedrooms are en-suite and two have a living and kitchen area. There is a large communal lounge and dining area, which had been decorated for Christmas. People have access to a large garden and patio from the lounge area; staff said this was well used during the summer The registered manager explained various refurbishments have taken place over the last year, carpets have been replaced; and some of the windows have Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 19 been replaced with double-glazing. Some of the bedrooms and the hallways have also been decorated. To make sure people consistently live in a safe environment, the annual quality assessment questionnaire states regular house audits are done, highlighting any work or improvements that may need doing. Also a maintenance file is kept to highlight any needed work in order of importance. To help prevent the spread of infections and to make the home a clean and comfortable place to live the annual quality assessment questionnaire states a cleaner is employed for twenty hours per week. Anti-Bac soap despensers are installed at all wash-points and Alco-Rub hand dispensers are available in all communal rooms, staff are instructed to adhere to the infection control policies and procedures. Where a person has expressed a wish to live in there own flat, the registered manager has accommodated this in the home. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35. People who use the service experience adequate quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to support people who use the service. However to make sure only suitable people are employed they need to improve their recruitment procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People living in the home said that they were generally enough staff available to meet their needs unless people were off work due to unexpected illness. Staff also confirmed this, and that there was enough staff available to make sure people could access the activities they choose. During the site visit staff had the time to sit and talk to people, also the staff rotas show that there is normally five to six staff on during the day for twelve people. Staff are clear about their role, knew what is expected from them and show a good understanding of the actions they needed to take to meet people’s needs in the way they prefer and need. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 21 Three staff records were looked at all showed that the home had not been ensuring they had received the necessary police check and reference documentation before staff started work to make sure they were suitable for the job. The registered manager explained people are recruited to the home by word of mouth and are therefore previously known to the manager and they had phoned for references but had not recorded this fully. Also the registered manager of the sister home makes the application to the criminal record bureau, so this was difficult to track. The registered manager agreed that the recruitment records and procedure needed to be more robust to make sure only suitable people are employed. She agreed to make sure all the outstanding documentation was followed up. There is an induction programme in place that ensures new staff members are given the right information to be able to do their jobs well. The registered manager explained appraisals are carried out yearly and supervision every two to three months; this was also confirmed in the staff surveys returned and by the staff spoken with during the inspectors visit. From staff’s appraisals a training development plan is made, this is then submitted to the provider for agreement, following agreement all training requirements are normally met. The training plan helps to ensure that training is provided to staff throughout the year. The 2007 plan showed assertiveness makaton, team building, dementia, understanding autism had been identified and planned for. However, although the records show moving and handling and first aid are generally up to date, some food hygiene, health and safety and safeguarding adults needs up dating. Staff confirmed they have regular meetings and the registered manager explained these are used as a opportunity to recap policies and to make sure staff are kept up to date and able to carry out their roles properly. People living in the home in their surveys all said staff do treat them well, and those spoken with also described how they generally ‘got on’ well with the staff. The annual quality assessment questionnaire states over half of the staff have their National Vocational Qualification level two or above in care, this qualification helps to make sure staff are properly trained to carry out the work. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37, 38 and 42. People who use the service experience good quality outcomes in this area. People benefit from a home that is managed in their best interests. We have made this judgement using a range of evidence, including a visit to this service EVIDENCE: The registered manager has worked for the provider since 1994 and has her registered managers award. During the site visit people were seen to be comfortable when approaching her to discuss the home, she always listened and responded with warmth and respect. Staff said they felt extremely well supported by the registered manager. Quality assurance systems consisted of an annual survey for people in the home to complete, regular house meetings, care reviews, and reviews of the Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 23 complaints and accidents records to identify any patterns etc. The home has also recently renewed the investors in people award. Two people living in the home said they felt involved in decisions that were made about it. Brackenley also produces an annual business plan, which helps it to prioritise areas for improvement. The annual quality assessment questionnaire states the maintenance and service records are in order. The fire safety procedures were in place and these showed equipment was maintained and staff have received the appropriate training. Accidents are recorded and reviewed by the registered manager to identify and resolve any potential risks. At the previous inspection the home was asked to provide the Commission with a copy of their most recent accounts, as there was concern the home had financial difficulties. The home has now supplied the accounts and the inspection evidenced that the registered manager and staff were confident that there were enough resources available to meet people needs. Brackenley DS0000007818.V352977.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 X X X 3 X Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 25 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. 1 Standard YA34 Regulation 19 Requirement To protect people using the service and to ensure only suitable staff are employed at the home the registered person must ensure that all staff have: • Completed a full application form and given details of previous employment. Any gaps in employment must be explored and details recorded. • Two satisfactory written references held on their personnel file. • A satisfactory CRB check in place. Where a POVA first check has been obtained there must be evidence that the staff member worked under supervision pending the receipt of the full CRB check. Timescale for action 03/01/08 Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 26 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 YA20 Good Practice Recommendations To make sure everyone is always aware of any risks there may be when a person is self-medicating the risk assessment should be recorded in the care records. Brackenley DS0000007818.V352977.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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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