Care Home: Brackenthwaite

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What the care home does well What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Brackenthwaite Senhouse Street Whitehaven Cumbria CA28 7ES Lead Inspector Diane Jinks Unannounced Inspection 10:00 14 August 2008 th 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 Brackenthwaite DS0000036544.V368240.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. Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brackenthwaite Address Senhouse Street Whitehaven Cumbria CA28 7ES 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) 01946 852561 www.cumbriacare.org.uk Cumbria Care Ms Susan Meyers Care Home 30 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (29), of places Physical disability (1) Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 30 service users to include: up to 29 service users in the category of OP (Old age, not falling within any other category) up to 3 service users in the category of DE(E) (Dementia over 65 years of age) 1 named service user in the category of PD (Physical disabilities) may be accommodated within the overall number of registered places. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users, and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 17th July 2006 3. Date of last inspection Brief Description of the Service: Brackenthwaite provides accommodation and care for up to 30 older people, 3 of whom may have dementia. The Home is situated in the centre of Whitehaven, close to all the towns services and amenities. Brackenthwaite is operated by Cumbria Care, an internal business unit of Cumbria County Council. The accommodation is provided on three floors and there is a passenger lift for ease of access. The Home is divided into three separate living areas. On the ground floor there is a lounge/dining room with small kitchen, plus a further quiet lounge with bedrooms, toilets and an assisted bathroom nearby. Also on the ground floor is another lounge/dining room, and the bedrooms and bathroom for the people who use this lounge are on the third floor. There is a lounge that can be used by those people who wish to smoke, and a spacious entrance hall with seating. On the second floor there is a lounge/dining room with small kitchen area, with bedrooms, toilets and assisted bathroom nearby. There is a garden area to the rear of the home with raised flowerbeds, a greenhouse and seating. There is parking to the side of the home. The home produces a guide to the services and facilities that can be provided and this is available on request from the manager. The scale of charges range from £386.00 - £449.00 per week (August 2008, subject to the assessment. Brackenthwaite DS0000036544.V368240.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 3 star. This means the people who use this service experience excellent quality outcomes. The assessment of this service took place over several weeks and included a visit to the home. People using this service, staff, visitors and relatives were asked for their views and opinions about the home, either during the visit or by completing questionnaires. The provider completed an Annual Quality Assurance Assessment (AQAA), which gave further information about the service and helped to verify some areas of the inspection process. The AQAA is a self-assessment of the service, which the manager usually completes. The AQAA completed by Brackenthwaite provides information about where improvements to the service have been made and identifies where further improvements will be made. We also undertook an annual service review (ASR) of this service. This was completed in December 2007. What the service does well: The service makes sure that people are consulted and have their health and social care needs assessed prior to making a decision to move into the home. This helps to ensure that the home will be suitable and able to meet their needs and expectations appropriately. People using this service are treated and respected as individuals. Care plans clearly show that people are asked about their likes, dislikes and wishes with regard to their daily lifestyle and people are supported and encouraged to remain as independent as possible. Some of the comments we have received from people living at Brackenthwaite, or their relatives include; • ‘I feel the care home provides a very friendly and homely atmosphere which you experience as soon as you enter the building. The staff are efficient and most pleasant nothing is a trouble.’ • ‘It provides a friendly environment. The staff are welcoming and helpful. The rooms are clean and they try to provide a variety of activities.’ • ‘One to one care is organised as carefully as possible to ensure continuity.’ The manager makes sure that staff are recruited and trained properly. This helps to make sure that people living at the home are cared for and supported in a safe and appropriate way. Staff told us; • ‘Training has really helped me in my job role and to maintain a high standard of cleanliness throughout the home.’ • ‘We all support each other in our working roles. We have confidence in our supervisors and management. I think we give a good all round service in every aspect of the needs and well being of the service user.’ Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Brackenthwaite DS0000036544.V368240.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 Brackenthwaite DS0000036544.V368240.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service have their health and social care needs assessed, usually before they move into the home. This helps to ensure that Brackenthwaite will be a suitable home and will be able to meet their needs and expectations. EVIDENCE: The home ensures that all prospective residents and, where appropriate, relatives are provided with sufficient information about the home. This helps them to make an informed decision about moving into the home. People who returned surveys say that they were provided with sufficient information to help them make the decision to move to Brackenthwaite. The information provided by the home states that prospective residents are able to visit the home and/or have a trial stay before moving into Brackenthwaite. This helps both the home and the prospective resident to be sure that the home will be able to meet their needs appropriately. Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 9 We looked at a sample of four admission and care records. They show that comprehensive pre admission assessments are undertaken before the home agrees to offer a placement. All the records have a copy of the terms and conditions of residency. This helps to make sure that people know what service they can expect from the home and also what services are included in the fees. The manager says that the statement of purpose and the service user guide for the home have been updated. Residents and families are given copies of these documents to help ensure that they are aware of the facilities the home can provide. These documents are available in different formats to help meet the needs of the people who may use this service. Brackenthwaite DS0000036544.V368240.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People using this service are treated as individuals. They have clear plans of their care needs and expectations and how those needs are to be met. EVIDENCE: We looked at a sample of four care records. The care plans recognise and respect the uniqueness of each individual resident. Their needs, expectations and wishes are presented in a very detailed person centred care plan. Staff at the home make every effort to ensure that all residents are treated with dignity and sensitivity at all times. This is reflected in the care plan documents. They are written as if by the person receiving care and support e.g. ‘I like to………….., I can do……………, I need help with………. Consideration is given to a person’s individual beliefs and diversity. Religion is recorded and whether a person practices this. One care plan in particular recognised a persons gender and recorded that they ‘likes nail polish, hand cream, moisturiser and likes to visit the hairdresser regularly.’ Another care plan identifies that the resident likes to be as independent as possible and the Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 11 care plan is written in a person centred way clearly showing likes, dislikes and preferences. It records that this is his first time away from home and reminds staff to be mindful of this to help reduce any anxieties he may have. This person practices their religion ‘and wants to be informed of when the church services are held in the home.’ The care documents give very clear information to staff about health and social care needs and how those needs are to be met. Staff strive to provide care and support in a sensitive and safe manner that reflects personal choices, aspirations and daily support needs. One relative commented; ‘One to one care is organised as carefully as possible to ensure continuity. This is important for my grandmother who is happy, settled and well cared for.’ Care plans are signed by staff and by the resident or a family representative. The records show that they are kept up to date and have been reviewed at least monthly, more frequently if necessary. A family member has recorded on one care plan review document ‘very happy. Everything been done 100 , thank you’. Care records contain an element of risk assessment and risk management. These documents are also regularly reviewed to help ensure that people using this service are supported safely. Daily records show that people have access to health care professionals such as the doctor, community nurses, opticians, speech therapists and dentists. Visits are made to the home, but residents are also supported to attend clinics and surgeries where possible. The home has a communication book, which is used in particular with the visiting district nurses. There is a very good relationship between the home and the nurses who often provide guidance and advice when requested. Medication is administered by the senior carer on duty with the help of a second checker who acts as a witness. Where people have had their medication needs reviewed this is recorded in their care files. Staff with the responsibility of administering medication have completed training either by distance learning course at college or via external trainers from the pharmacy. People responsible for acting as a witness to medication administration have undertaken some in-house training. We looked at the medication and the records of four people who live at the home. The records we looked at were up to date and accurate. The home obtains and keeps patient information sheets about individual medications. Medicine packs are colour coded according to the time of administration and this helps to make sure that they are given at the correct time. Information about ‘homely remedies’ and medication that can be taken ‘as and when required’ is kept on each individual file, with records kept of administration. The home has a designated fridge for medicines requiring cold storage and temperatures are checked daily. Where medicines in liquid form are required, these are obtained where possible. The home has satisfactory arrangements in place for the safe keeping of drugs that may be liable to misuse, including secure storage and clear recording systems. Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service are offered a variety of leisure and social entertainments. This means that they are able to and encouraged to make positive choices about their lifestyle. EVIDENCE: The home employs an activities co-ordinator to help ensure that people living at the home are offered a wide range of social and leisure activities. Care plans show that people are asked about their interests and hobbies and demonstrate that choices are offered and that people are respected as individuals. Records are kept of the activities that take place at the home. Activities include: games, outings, dominoes, armchair aerobics, bar meals, singing and arts and crafts. The travelling library visits the home and visits are made by the Pets as Therapy service. A pet dog has recently visited and one resident in particular told us that they enjoy this activity. People also have access to church services at the home and religious leaders of various faiths make visits. Residents meetings take place and minutes are kept of the topics discussed. These include healthy eating, menus, food in general, activities, trips out, redecoration of the home and the new bath, which has recently been installed. Breakfast menus are available throughout the home and people have an extensive choice, including a full cooked breakfast if they wish. Similarly, Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 13 menus have been reviewed to include the full choice of sandwich fillings and jacket potato fillings. The chef was spoken to during the visit to the home and a brief visit was made to the kitchen. Food tasting days have been held and the chef frequently speaks to residents to find out about their likes/dislikes/preferences and views on the meals served. The chef and the kitchen at the home has been visited by the local council’s Food Safety Officer – it has been awarded 4 stars for food safety and assessed as being very good. The service of the lunchtime meal was observed in one of the units. This was a very pleasant and sociable affair. Residents were assisted to the table and with their meals where necessary. There was a choice of two hot meals on the menu, but people are able to choose other alternatives if they wish. One of the residents we spoke to told us that the food is very good and that she had put on weight since moving into Brackenthwaite. They added that the ‘staff are very good. They help with making telephone calls to my relatives if necessary.’ Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service know how to raise any concerns they may have. They are confident that concerns will be taken seriously and dealt with properly. EVIDENCE: The home has a procedure in place to help people make comments or complaints. It also helps people who use the service to understand what will happen to investigate concerns if any are raised. All of the people that returned questionnaires to us said that they know who to speak to if they are not happy about something. They are confident that the manager will take their concerns seriously and deal with them properly. Two people commented that; ‘any small issues and requests have been dealt with right away.’ Copies of the complaint process are available in the home and are included in the service user guide and statement of purpose documents. The complaint process is also available on audiotape to help meet the communication needs of some of the people that use this service. The home has policies and procedures in relation to the safeguarding of vulnerable adults (abuse). Staff at the home have received training in this subject to help make sure that they understand abuse and when matters should be reported for further action. The home has copies of the local authority’s guidance on safeguarding and protecting adults from harm and abuse. This will help to ensure that the home follows the correct process should they need to report matters to social workers. Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Brackenthwaite provides a warm, comfortable and pleasant environment for the people that use this service EVIDENCE: During our visit to this service we walked around the home. We found the home to be fresh and clean throughout. The manager employs domestic assistants to help make sure that the home is kept in a clean and hygienic condition. Each unit at the home has a lounge/dining area with a small kitchenette, used for making drinks, snacks and serving the meals. The lounge areas are furnished and decorated to a good standard and make comfortable seating areas for the people that live at Brackenthwaite. The televisions at the home have recently been replaced to accommodate the digital switchover and enhance viewing quality for residents. There is a designated smoking room for those residents who wish to smoke. There are various options for residents to sit in – communal lounges, conservatory and a quiet room. The communal bathrooms are warm and cosy. The finishing touches of mirrors, pictures, Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 16 candles and co-ordinating bath towels help to make these rooms a homely and relaxing environment. The home has recently had a new bath fitted. The bath is specially designed so that people of all abilities should be able to access these facilities, with help if necessary. We also looked at some of the bedrooms at the home. Residents have personalised these with some of their own belongings from their own homes. People are able to bring small items of furniture, ornaments, pictures and have their own televisions and music centres in their rooms if they wish. Some people have had personal telephones put in their rooms. These are not included in the fees for the home and people are responsible for their own telephone bills in these circumstances. One person is not able to sleep in a regular bed. Arrangements have been made to help ensure that this person is safe, comfortable and able to sleep well each night. Some of the people who participated in this inspection made comments about the environment at the home. One person said; ‘My room is very clean and lovely. I like the home and very happy with everything.’ Another person commented; ‘The cleaning staff work hard and keep everything very fresh. Their rooms are kept very clean and tidy, what a lovely environment.’ We made a brief visit to the laundry. It was in a clean and tidy condition. Protective clothing and special laundry bags are available to help reduce the risk of cross infection. A short visit to the kitchen was also made. The kitchen was in a clean, tidy and well-organised condition. The chef has cleaning rotas in place to help ensure that this area in particular is kept in a clean and hygienic condition. Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are supported by safely recruited and well-trained staff. This helps to make sure that people are supported and protected from harm by staff that understand their needs and requirements. EVIDENCE: We looked at some of the staff files, including recruitment and training records. We found that there is a robust recruitment and selection process in place at the home. Staff do not commence working at the home until all of the checks have been made, including Criminal Record Bureau checks (CRB) and obtaining two written references. These checks help to make sure that staff are suitable to work with vulnerable adults. Staff training records show that training is given high priority. Most of the staff at the home have completed or are in the process of completing National Vocational Qualifications in various subjects and at various levels. The training programme not only includes all of the care staff but also the ancillary staff such as the housekeepers and kitchen staff. Records show that care staff attend induction training when they first start working at the home. This helps to ensure that they know what is expected of them and that they work safely with residents. Other training that staff have undertaken includes dementia care, POVA(abuse), principles of care, medication, health and safety, manual handling, nutrition and infection control. The manual handling training is due to be refreshed for staff. The home has Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 18 two staff on site who are qualified to train others in this subject. This helps to ensure that the training contains elements, which are specific to the home, the needs of people living at the home and the equipment in use at the home. The staff rota indicates that there are a sufficient number of staff on duty to meet the current needs of the people living at Brackenthwaite. We observed staff working with some of the residents. Good manual handling techniques were seen. Staff had a pleasant and friendly attitude towards residents, assisting them with a variety of things when needed. Staff had time to chat to residents and ensured that they had plenty of drinks throughout the day. Lunch was observed in one of the dining areas. This was served nicely and residents were consulted or reminded of the choices they had made for their meal. Where people needed assistance, this was done discreetly and with sensitivity. Staff were polite and cheery. One person was waiting for a lift to a dental appointment and staff checked the time for this. The person was ready a bit too early. Staff encouraged them to go and have a drink whilst they waited. The cook came out of the kitchen and discussed the meals with the residents. People say that she often does this and minutes of residents meetings show that she attends these too. This helps to ensure that people are able to voice their opinions about meals and what they would like to eat. The cook said that she likes to go and speak personally to new residents to ensure she knows what they like and if they have any special dietary requirements, although this information is usually passed to her by the manager when a person comes to live at the home. Some people we spoke to made comments about the staff. They included; ‘The staff are efficient and most pleasant nothing is a trouble and what patience they have!’ and ‘The kitchen staff work hard and provide excellent, appetizing and always fresh food which is very varied.’ Another person commented; ‘I am very satisfied with the care home the staff do their job well they are friendly they always make me feel welcome and my mum is well looked after. I can rest knowing that my mum is ok there.’ Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of people using this service and residents are consulted upon their views and opinions about the home. EVIDENCE: The manager is experienced and qualified to run the service. She keeps her knowledge and training up to date and is planning to complete training on the Mental Capacity Act soon. Copies of CSCI guidance are kept in her office and are well used by her and staff. The service works well with us. The manager has ensured that any requirements and recommendations that we have made have been addressed or implemented. She also ensures that we are notified of any incidents, which may adversely affect the health and well-being of people using this service. The manager was described as a ‘very conscientious person’, they added; ‘as you know in all things everything comes from the top Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 20 and here we see someone who is dedicated and always accommodating whenever possible. This permeates right down through all the staff.’ We looked at a sample of records relating to resident finances. Individual records are kept together with receipts where purchases are made on behalf of residents. The records are always signed and witnessed by two people – one of which is either the manager or a senior carer. Weekly audits/spot checks take place as a further security measure. The records are carefully maintained and accurately kept. This helps to ensure that money and valuables belonging to people using this service are kept safe and securely. We looked at a selection of records, which the manager is required to keep by law. The accident book was looked at and accidents have been recorded and where appropriate notifications have been sent to us. Other records including some maintenance records and safety records were looked at and found to be up to date and accurate. There is a service development plan in place at the home. Both staff and residents have access to this plan. People using the service are regularly consulted about the home and the service they receive. Their relatives and friends can also contribute to this process and questionnaires are available for them to complete. These consultations help the manager identify areas for improvement. Two of these areas include – a greater use of community resources, reflecting individual interests of people using this service and continue consultations with residents about the meals and the menus at the home. Staff are also included in the survey, again with further areas identified for development, including person centred care planning and monthly afternoon teas so that residents can invite their families or friends to the home. Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 21 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 22 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 Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brackenthwaite DS0000036544.V368240.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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