Care Home: Braeside

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What the care home does well What has improved since the last inspection? To provide assurances and clarification, letters were now being sent to prospective residents following their initial assessment. Nutritional assessments had been introduced in each persons care plan, to help manage appropriate diets and food intake. To make surer food is stored at a safe temperature, the fridge temperatures were being monitored and adjusted accordingly. To help inform residents of the food being provided, the day`s menu was being displayed in the dining room. Some additional activities had been introduced, including a visiting sweet shop and exercise sessions. To make sure managers and staff do the right thing to protect people living at, Braeside some guidelines had been changed and further training had been provided. To help make sure complaints are properly dealt with some procedures had been updated. To help keep the home clean and fresh, a better carpet cleaner had been obtained. The outside decking had been refurbished and extended, to provide an attractive and accessible outside area forth residents. CARE HOMES FOR OLDER PEOPLE Braeside Stanhill Lane Oswaldtwistle Accrington Lancashire BB5 4QF Lead Inspector Mr Jeff Pearson Key Unannounced Inspection 28th August 2008 09:20 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 Braeside DS0000009500.V358792.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. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Braeside Address Stanhill Lane Oswaldtwistle Accrington Lancashire BB5 4QF 01254 398099 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) brae-hfe@tiscali.co.uk Mr George Anthony Hitchen Mrs Christine Philomena Hitchen Mrs Jennifer Mavis Brimlow Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2007 Brief Description of the Service: Braeside is a care home providing accommodation and personal care and support for up to 24 older people. Braeside is a detached property set in its’ own grounds, situated on the main road in Oswaldtwistle, it is within reach of local amenities. There is a parking area for visitors at the rear of the home. The accommodation is provided on two floors, bedrooms are single, sixteen have an en-suite toilet and washbasin. There are two lounges and a lounge/dining room. An attractive outside decking area is accessible to residents from two of the lounges. All furnishings and fittings are domestic in style and equipment is available to offer assistance with self-help and mobility. Staff are on duty 24 hours per day to provide for the individual needs of the residents. The home had available a Statement of Purpose and Service User Guide providing information about the support, care and services available. This information should help people make an informed choice about moving into Braeside. At the time of the inspection visit the range of fees was between £366.00 and £412.00 per week. Personal toiletries, clothing and hairdressing were not included in the fees. Braeside DS0000009500.V358792.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 people using this service experience good quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Braeside on the 28th August 2008. The visit took almost 8 hours and was carried out by one inspector. The people living at the home, their relatives and staff were invited to complete surveys, to tell the Commission what they think about the care service provided at Braeside, some were received at the Commission. Before the site visit, the registered manager was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of three people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with people living at the home; the registered manager, staff and a relative. Various documents, including policies, procedures and records were looked at. Most parts of the home and outside areas were viewed. What the service does well: The home was being run by a team of staff, who were keen to provide a good service for the residents. Relatives completing surveys, made the following comments on what they felt the home does well – “The home is always clean and tidy without smells or unwanted odours” and “This is my second relative who has used this home and both have been given first class care”. A relative spoken with during the inspection visit said, “mum has come on leaps and bounds, it’s a lovely home” People were getting attention for health care needs and personal privacy needs were being dealt with sensitively and they were being treated with respect and as individuals. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 6 Most people were happy with the arrangements for activities and daily routines were fairly flexible. People liked the food at Braeside; they said was “good”. Positive comments were made about the staff team, one resident said, “The staff are very good” To help make sure staff provide effective care, good arrangements were in place for ongoing training and development. What has improved since the last inspection? To provide assurances and clarification, letters were now being sent to prospective residents following their initial assessment. Nutritional assessments had been introduced in each persons care plan, to help manage appropriate diets and food intake. To make surer food is stored at a safe temperature, the fridge temperatures were being monitored and adjusted accordingly. To help inform residents of the food being provided, the day’s menu was being displayed in the dining room. Some additional activities had been introduced, including a visiting sweet shop and exercise sessions. To make sure managers and staff do the right thing to protect people living at, Braeside some guidelines had been changed and further training had been provided. To help make sure complaints are properly dealt with some procedures had been updated. To help keep the home clean and fresh, a better carpet cleaner had been obtained. The outside decking had been refurbished and extended, to provide an attractive and accessible outside area forth residents. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 7 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. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 8 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 Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 9 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): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The admission process helped ensure peoples’ needs and wishes, were considered and planned for before they moved into the home. EVIDENCE: The manager explained the usual admission process, people would be encouraged to visit and an appointment would be made for an assessment to be carried out, initially general information would be obtained, from the resident and their families an others such as Social Services, as appropriate. People would be given a copy of the homes guide and where possible encouraged to visit, the manager said the aim was for the person to spend a day at Braeside to enable them to meet staff and current residents. For those not able to visit, the manager said she had explained as much as possible Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 10 about the home. Admission packs were seen to be available, for new people. Comments in surveys indicated people had been given sufficient information about the home, one person wrote, “Braeside was recommended by a good friend” A relative spoken with said they had re-visited the home when not expected and was “delighted with attitude of manager and staff” The AQAA (Annual Quality Assurance Assessment) completed by the manager, indicated that the homes guide was due be reviewed and updated. Records showed assessments had been completed; taking into consideration peoples individual needs abilities and wishes in matters such as, personal care, mobility, communication, risk of falls and peoples’ meal preferences had been sought. It was advised the assessment format be developed, to ensure cognitive needs are considered. Social Services assessments were available as appropriate. Copy letters confirming acceptance to the home were seen. Contracts had been up-dated to include more current details. The manager said it was the homes policy to offer trial visits At the time of this inspection Braeside did not provide intermediate care. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 11 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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most health and personal care practices and procedures were effective in ensuring people’s individual needs are sensitively met. EVIDENCE: Residents spoken with were satisfied with care and attention they received at Braeside. This response was also reflected within most surveys completed by residents and their relatives. With residents indicating they always get the care and support they need. One comment made was “staff are very observant and notice when my health changes even if I dont notice myself” All staff completing surveys indicated they always had up to date information about peoples needs. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 12 Care plans were looked at as part of ‘case tracking’ The format in use provided scope for peoples’ individual needs to be identified on a range of relevant matters, such as nutrition, mobility and state of mind. However, they were lacking in detail and clear instructions for staff to follow in order to properly respond to peoples’ individual needs. For example, one plan stated, “assistance with personal needs care”, which was not detailed enough to effectively instruct staff in promoting continuity of person centred care. This lack of precise directions to staff meant that provision of care is largely dependant upon staff memory, with a potential for care needs not being properly met. The care plans seen were also lacking in instructions for responding to social and behavioural care needs. It was also advised that any family involvement should be agreed in the care planning process. Records showed that peoples care needs were being monitored and regularly reviewed. The manager said care plans were continually being developed and that she was very keen to improve their content. Health care needs were included with care plans; additional assessments had been completed in relation to pressure areas and nutrition. Records and discussion showed people were getting attention from healthcare professionals such as GPs, District Nurses and Chiropodists. All residents completing surveys indicated they always receive the medical support needed, one wrote, “staff always take care of medical conditions quickly” One comment made by a relative was, “medical conditions are fully catered for” Medication storage was satisfactory, clean and secure, the manager said a fridge was soon to be obtained, it was advised that this be lockable. Medication policies and procedures were available, there was no policy guidance on covert administration, or procedures directing staff to assess peoples ability to self administer, the manager said they were due to be reviewed and updated in line with current best practice. Most medication records seen, were accurate, clear and up to date, but there were some discrepancies needing attention, such as there was one gap with no explanation given, so it was not clear of the person had taken their medication. To promote independence, some people were being supported to selfadministering some items, but there were no assessments to show their ability to do this had been properly considered. The residents spoken with did not express any concerns about how they were treated. Observations of care practices during the inspection showed peoples’ privacy needs were being respected; staff were seen knocking and awaiting a reply before entering bedrooms and they spoke with residents in a courteous manner. People were being supported to maintain their appearance, one resident said, “they make sure you have clean clothes” and a hairdresser made regular visits to the home. Sensitive consideration and attention had been given to peoples’ wishes regarding their end of life. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 13 Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 14 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): 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 living at Braeside had opportunities to make choices, join in activities and had lifestyles that generally matched their expectations. EVIDENCE: The residents spoken with indicated they were generally happy living at the home, “I am very happy living at Braeside” said one person “it couldn’t be better” said another. Routines seemed flexible, it was apparent the residents could spend time in their rooms whenever they wished “I like to spend some time in my bedroom, but go out in the grounds with my daughter most afternoons”, explained one person. Residents’ surveys indicated they were “usually” happy with the activities available. A list of possible activities was seen, including craft sessions, keep fit, beetle drive, manicures, reminiscence, sweet shop and bingo, usually some activity was arranged each afternoon. A comment from a relative on what the home could do better was, “more stimulation and interaction between staff and residents”. Residents meetings were being held annually and the manager Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 15 said she spends time chatting informally with people, it was advised such discussions be noted to help promote continuity and show how people had been consulted about matters which affect them. As previously indicated, social care needed to be better reflected in the care planning process to make sure all needs are effectively addressed. The AQAA (Annual Quality Assurance Assessment) completed by the manager, showed the provision of more varied entertainment and religious services to be matters for future development. The homes’ visiting arrangements were included in the homes’ guide; the residents spoken mentioned the contact they were having with families and friends. One visitor spoken with said they were always made welcome at the home. A survey from a relative included the following, “open visiting is encouraged, any special visits wanted are just a phone call away” The residents spoken with were happy with the food provided at Braeside they said, “I’m satisfied with the meals” and “the food is very good” Surveys include comments such as “meals are always prepared and presented to a high standard” “food is always good and wholesome and presented well and there is always more if wanted”. The weekly menu on display in dining room, a set meal was usually offered at lunchtime, the cook and manager said alternatives could be provided. Various cereals were on offer, with a cooked breakfast provided at weekends. Some choices were routinely offered at teatime, for example, spaghetti or baked beans, various sandwiches. Special diets, such as diabetic were being catered for and a dietician had been consulted, for specific advice. As a choice of meal was not always routinely offered at lunch, ways of providing regular options was discussed with the manager and cook. Braeside DS0000009500.V358792.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices provided safeguards for people using the service and supported the complaints process. EVIDENCE: Residents completing surveys and those spoken with, indicated they knew how to make a complaint, comments made were “I have no complaints” and “No grumbles”. All relatives completing surveys said they knew how to make a complaint, half indicated they thought any concerns were properly dealt with. There had not been any recent complaints; the last complaint was discussed with the manager. Advice was offered in relation to the management of complaints, in particular, remaining impartial, devising investigation strategies and ensuring systems make proper provision for the recording of interviews, discussions and all action taken. The manager said the complaints policies had bee revised and updated since the last inspection, it was suggested the local Social Services contact details be included in the complaints procedure. All staff completing surveys indicated they were aware of how to respond to concerns or complaints made by residents and others. Residents’ surveys indicated they knew who to speak to if they were not happy. Since the last inspection, all staff had received POVA (protection of vulnerable adults) The manager said the homes safeguarding policies and Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 17 procedures had been updated following the training. The staff ‘reporting bad practice’ procedure had been produced as separate guidance and included the appropriate contact details of the Commission. Manager said each persons care plan included an assessment, regarding any potential physical intervention or restraint. Braeside DS0000009500.V358792.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The accommodation at Braeside provided the residents with a comfortable and clean place to live. EVIDENCE: The residents spoken with were satisfied with the accommodation provided at Braeside, they had been enabled to personalise their bedrooms with their own belongings, which helped create a sense of home and ownership. One resident said, “I like my bedroom very much”. The communal lounges and dining area were pleasantly decorated and provided comfortable and homely surroundings. Since the last inspection changes had been made arrangements for smoking. The outside decking area had refurbished and provided a very attractive outside space of the residents, discussion took place with the manager regarding assessing the outside areas to ensure any potential risks are Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 19 minimised. Arrangements were in place to ensure ongoing maintence and repairs, some repairs such as radiator covers and door guards were ongoing. The bathing facilities were viewed; action was taken at the time of the inspection to provide a more appropriate shower seat in one bathroom. The suitability of the ground floor ‘medi bath’ was discussed with the manager, it was suggested the homes’ long term development plans make provision for this facility to be replaced. The first floor bathroom, which had a conventional bath, was not currently being used, mainly as it was not accessible to most residents. To promote dignity and choice, it should be adapted to more effectively meet the needs of the people with bedrooms on the first floor. The home was found to be clean and mostly free from unpleasant odours. One comment from a resident was “I have always found the place to be lovely and clean no odours at all” Satisfactory laundry equipment and facilities were available; it was suggested liquid hand wash and paper towels be provided in the laundry, however, the manager explained staff have their own anti bacterial hand wash. Arrangements were in place to keep the home clean; a new industrial carpet cleaner had been obtained. Plastic aprons and gloves were available to staff. Infection control policies and procedures were available. There was an indication within the AQAA (Annual Quality Assurance Assessment) completed by the manager that the home was to be refurbished and decorated. Braeside DS0000009500.V358792.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. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The staffing arrangements provided people at Braeside with satisfactory care and support. EVIDENCE: Residents spoken with made positive comments about the staff team, describing them as “Very good” one person said, “They are all grand” The staff rota indicated staffing levels were mostly satisfactory. However, it was noted that there was no cook on duty at teatimes, with designated care staff having to assist with food preparation and serving. This raised questions on providing safe and effective support for the numbers and needs of the people accommodated. The manager said she would look into this matter to ensure support was provided. Some residents considered there were ‘sometimes’ and ‘usually’ enough staff available. Since the last inspection, further improvements had been made with staff training; this was being given high priority at Braeside. All of the care team had NVQ (National Vocational Qualifications) level 2, eight staff had attained NVQ level 3, four had commenced this. The deputy manager had NVQ level 4. one cook had and NVQ 2 in catering. Training courses in safe working Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 21 practices, such as Safe Food Handling, First Aid and Moving and Handling, had been completed and were going. The manager explained the home has a very low staff turnover. Staff surveys indicated they considered appropriate recruitment practices had been carried out. The recruitment records of the last member of staff to be employed were examined, and were found to be mostly satisfactory. However, the application form did not require a signed statement from the applicant regarding any previous convictions, offences are cautions, therefore this initial screening was not being effectively carried out. Records were seen of staff induction training, a staff hand book and induction checklist was in use, new recruits worked alongside senior staff. Staff surveys indicated this had covered everything very well. New staff were being supported to undertake NVQ and mandatory training courses. Braeside DS0000009500.V358792.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most management and administration practices were effective in ensuring the home is run for the benefit of the residents, staff and visitors. EVIDENCE: Jenny Brimlow has been registered manager at Braeside for several years, she has a Registered General Nurse qualification and has attained the registered managers award. She has updated her training in areas such as, health and safety, basic food hygiene, moving and mental capacity act training. Surveys included positive comments about the management of the home, one resident wrote, “The manager of Braeside is always ready to help and listens to whatever I have to say” and member of staff commented “I know that if I have Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 23 any problems concerning work or personal problems, both the owner and line manager are there to help” Various surveys and questionnaires had been given to relevant people, including, residents and families. The manager said all surveys were being read and collated with any issues being acted upon accordingly. It was also advised the results/findings of quality surveys be included as evidence within the AQAA (Annual Quality Assurance Survey). Ensuring enough details are noted and using the AQAA proactively, for ongoing quality assurance and developing the service was discussed with the manager. The homes AQAA indicated the servicing and checking of equipment and installations, records were seen in support of this. Records were seen of weekly fire alarm testing and fire drills. Fire risk assessments had been completed. Health and safety risk assessments had been carried out around 18 months previously. It was therefore suggested they be reviewed and updated, with all radiators and outside areas being considered. Training in safe working practices was ongoing. Braeside DS0000009500.V358792.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 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Braeside DS0000009500.V358792.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. 4. Standard OP29 Regulation 19 Schedule 2 Requirement For the protection of the residents, recruitment practices and procedures must always ensure details of any criminal convictions and cautions are disclosed as appropriate and with records kept. Timescale for action 01/10/08 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 OP7 Good Practice Recommendations Care plans should be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents personal and social care needs. To make sure people are safely supported to manage their own medication, their individual abilities need to be assessed and planned for. Medication policies and procedures should be revised and updated in line with current best practice. A suitable auditing system should be introduced to ensure safe medication practices. DS0000009500.V358792.R01.S.doc Version 5.2 Page 26 2. OP9 3. 4. OP9 OP9 Braeside 5. OP15 6. OP21 7. OP27 8. OP38 To cater for more effectively for individual tastes and preferences, further choices should be routinely offered at lunchtime. To more effectively meet the needs of the residents, promote dignity and choice, action should be taken to review and up grade the homes bathing facilities. To ensure people are effectively and safely supported, staffing levels should be continually reviewed and adjusted accordingly. To help promote a safe environment, health and safety risk assessments should be reviewed and updated and completed all outside areas accessed by residents, staff and visitors. Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Braeside DS0000009500.V358792.R01.S.doc Version 5.2 Page 28 - 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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