Care Home: Breach House

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What the care home does well Information is available about the service, and what can be provided to help people and their families in making decisions about their future care needs. Opportunities for introductory visits and short stays are provided to help with these decisions. People say they are happy living at the home. People are given help and support to make choices in their daily lives and say they are treated with dignity and respect at all times. A variety of activities are provided and people can choose to take part if they want to. Breach House provides opportunities and support for people to maintain their interests and any hobbies they may have. Breach House looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Breach House. Staff are trained to help them understand how to meet people`s needs and give them the support they want. Breach House makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Breach House. People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly.People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. What has improved since the last inspection? The statement of purpose and service user guide has been amended to include all required information. All staff involved in the administration of medication have received accredited training to help make sure medication is given safely. The manager and the deputy manager have completed training in the protection of vulnerable adults. The floor covering in the corridor has been replaced. The communal toilets have been fitted with door locks that make sure privacy is maintained but allow for emergency access. Handrails have been fitted to the corridors to provide additional support for people. The manager and the deputy manager have completed a four-day training course in first aid. What the care home could do better: Information sheets provide details of each person`s medication. The frequency of administration of medication is abbreviated. It would be good practice to put an explanatory key at the top of the page where abbreviations are used. It is considered good practice to provide information on each medication and any possible side effects, to help staff to give the care and support people need. The manager should complete a report on the quality assurance review and monitoring that has been completed to measure how well the aims and objectives of the service are being met. CARE HOMES FOR OLDER PEOPLE Breach House Holy Cross Lane Belbroughton Stourbridge West Midlands DY9 9SP Lead Inspector Dianne Thompson Key Unannounced Inspection 23rd March 2008 09:00 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 Breach House DS0000018495.V361156.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. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breach House Address Holy Cross Lane Belbroughton Stourbridge West Midlands DY9 9SP 01562 730021 01562 730021 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) Miss Karen Ann Hucker Mr Michael Gordon Hucker, Mrs Hilary May Hucker Mrs Julie Anita Head Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability over 65 years of age (26) Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th September 2006 Brief Description of the Service: Breach House is a large, detached property that was formerly a farmhouse. The premises have been adapted and extended for their present purpose as a residential care home for older people. The property occupies a level site and is situated in a rural area in approximately two acres of ground at the end of a long driveway on the edge of the Belbroughton village. People who use the service are accommodated in single bedrooms, some of which are large enough for two people, on three floors. Twenty-four of the bedrooms have an en-suite facility. The home has a passenger lift to enable people who are accommodated on the first and second floors to access their bedrooms more easily. One bedroom is served by a stair lift. There are two lounges, a dining room and a conservatory. The home provides communal bathroom and toilet facilities. The garden is attractive and well maintained and there is adequate car parking space near the front of the building. The home operates as a family business and a registered manager is employed to be responsible for the day-to-day running of the home. At the time of the inspection there were 24 people resident at the home and one person was in receipt of short-term respite care. The details of fees are included in the Service User Guide. Breach House DS0000018495.V361156.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 stars. This means the people who use this service experience good quality outcomes. This was an unannounced inspection visit to see what the home was like for the people who live there. Time was spent talking to some of the people who live at Breach House and some of the staff working there. We looked at some of the policies and procedures in the office with the registered manager. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). A tour of the premises was also made. Information gathered from other sources, such as monthly visit reports and notifications sent to the CSCI, has been included in this report. What the service does well: Information is available about the service, and what can be provided to help people and their families in making decisions about their future care needs. Opportunities for introductory visits and short stays are provided to help with these decisions. People say they are happy living at the home. People are given help and support to make choices in their daily lives and say they are treated with dignity and respect at all times. A variety of activities are provided and people can choose to take part if they want to. Breach House provides opportunities and support for people to maintain their interests and any hobbies they may have. Breach House looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Breach House. Staff are trained to help them understand how to meet people’s needs and give them the support they want. Breach House makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Breach House. People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 6 People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. 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. Breach House DS0000018495.V361156.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 Breach House DS0000018495.V361156.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): 3, 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is available about the service, and what can be provided to help people and their families in making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Breach House has policies and procedures in place for assessing potential people to live at the home. Information about the home included in a Statement of Purpose and Service User guide is available and provided for all enquirers and residents. People are given an information pack containing a copy of the statement of purpose and service users’ guide on admission. Three people spoken to confirmed that they had received copies. An updated copy of the Statement of Purpose and the Service User Guide was made available during the inspection Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 9 visit. The statement of purpose and the service users’ guide has been amended to include all of the required information, including fee details. Evidence was seen to show full community care assessments have been received and in addition Breach House complete their own assessments. Care plans are written from the information gathered during assessments, visits and discussions with families and other interested parties. The form that is used by the service for assessing individual needs has been amended. A person recently admitted to Breach House confirmed introductory visits had taken place and that information about the home had been provided before a decision was made to move to Breach House. It was confirmed that a contract had been given that identified the room the individual was to occupy. A visiting relative confirmed that they and their relative had been given copy of the service user guide and the statement of purpose in an information pack. Surveys confirmed that information about the home is shared, and that people are kept up to date with important issues. Breach House DS0000018495.V361156.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): 7, 8, 9, 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Breach House. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. Breach House has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Care plans for four people were viewed and all contained appropriate information about their needs and how they were to be met. The plans for each person are based on initial assessments completed before being admitted to Breach House. Information provided in these care plans covers all aspects of each person including their daily living needs, health and personal care, Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 11 physical well-being, social interests and relationships, religious and cultural needs and any other specific areas. The care plans set out in detail the action that needs to be taken by care staff to make sure that all needs are met. Evidence shows that care plans are regularly reviewed, and are used as a working document. An example of good practice was seen where changes to care needs have been identified. The dates are highlighted to make sure all staff are fully aware and make changes to their practice. People living at Breach House confirmed that they are involved in their care planning and that their care needs are discussed with them and their family. Staff said they are fully aware of the plans and follow them to guide their practice. Each person is allocated a key worker to oversee his or her care. This allows staff to work on a one-to-one basis and contribute to the care planning for each person. Photographs of allocated key workers are hung on each person’s bedroom wall so they know who their key worker is. Risk assessments are completed to keep people safe, with suitable guidelines for assistance as necessary. This includes mobility, moving and handling, pressure care and nutritional needs. Completed risk assessments show dates for planned reviews and explore ways to make sure that people are able to be as independent as possible. A relative’s view of the care and support provided at Breach House is that their mother ‘is well cared for and is very happy’. Other surveys confirmed that care given is what they expected or agreed with the service. Comments from people who use the service include: ‘They look after me well – I have been here over 3 years now and I am very happy with my life here’. ‘I can choose to stay in my room or take part in singing or other things that are put on’. ‘I can go for a walk if I want I like to keep going. I am watching the arguments in parliament on TV now’. People have good access to medical support through their Primary Health Care team as required. A record of visits to the home by doctors or other medical professionals is maintained. A Chiropodist visited the home during the inspection visit. Staff were observed providing support for people in a respectful way, making sure that dignity and self esteem was important for each person. The home has two lounge areas and a medical room for meetings if people do not wish to take visitors to their bedrooms. People appeared to be comfortable and at ease in their surroundings. People living at Breach House said they found staff ‘helpful’, ‘caring’ and ‘they treat me like royalty’. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 12 A policy and procedure is in place for the administration of medication. The registered manager provided evidence to show that the policy and procedure is reviewed at least once a year and is signed and dated. All the staff who are involved in the administration of medication now receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems that may occur. Medication is stored securely and given to people at the right time and full records are kept which show this. A medication sheet in each care plan gives details of currently prescribed medication. The frequency of administration is abbreviated. The manager was advised that it would be good practice to put an explanatory key at the top of the page where abbreviations are used. Additionally, it would be good practice and help staff in their care practice to provide information on each medication and any possible side effects. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive help and encouragement to make choices and decisions about their lives. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Breach House are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People are able to make a choice about how to spend their day and examples of this were observed throughout the inspection visit. One person said ‘I can do what I want to do and when I want to do it’. Various recreational activities are offered to help people maintain their interests. Evidence was seen in care plans to show daily routines and support given for specific interests. Activities are recorded in each persons care plan. Activities on offer include movement to music, playing board games, musical quiz, bingo, hairdressing and skittles. Occasional trips are arranged and Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 14 seasonal celebrations are also organised. Trips include visits to the local pub and garden centres. A mobile library visits on a regular basis. A musical quiz took place during the afternoon of the inspection visit. Breach House has a large garden and people are encouraged to spend time there, particularly in the summer. Some people were seen walking in the garden during the afternoon. Breach house has a room that has been converted to a hair salon. The hairdresser was cutting people’s hair during the inspection visit. Regular residents meetings are held and discussions include menus and activities. Minutes of these meetings are kept. Evidence shows that regular contact with friends and family is supported. People who use the service confirmed that they are able to see their visitors in private, and that their visitors are made welcome and offered a drink. This was observed during the inspection visit. One relative visiting at the time of the inspection said they visit on a regular basis and that they are ‘always made to feel welcome’. Records show that varied and nutritional meals are provided and alternative meals where these have been chosen. People are offered three full meals, with snacks and drinks available throughout the day. Details of the daily menu are displayed in the notice board in the dining room. People are consulted about their choice of food and diets. The inspector was invited to join everyone for lunch. The atmosphere in the dining room was relaxed and pleasant with easy and comfortable interaction between staff and residents. The lunch choice consisted of omelette (plain or cheese), fried eggs, or meat pasty with chips and peas, followed by stewed apple and custard. A cold drink was available for those who wanted it. People who use the service said they ‘liked the food’, and thought the ‘choices are very good’. ‘Food always good here, its like a first class hotel’. ‘They use the best butchers for meat and there is always fresh fruit and veg’. Alternative options were offered during lunch where people had forgotten what they had ordered or where people wanted something different. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. There are suitable policies and procedures in place to make sure that people who use the service are protected from abuse. EVIDENCE: Breach House has a complaints policy and procedure in place which is accessible to people who live at the home and their relatives. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. One person explained that ‘I know who to talk to if I need to, but I don’t have any complaints’. The complaints log was seen and the manager confirmed that no complaints have been made to the service. The CSCI has not received any complaints about the home. Procedures are in place that guide responses to any allegations of abuse and in managing any complaints made about the service provided. The policy and procedure on the protection of vulnerable adults from abuse and the ‘whistle blowing’ policy has been amended in accordance with the guidance given in the Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 16 previous report. Staff receive training in abuse awareness. The registered manager and deputy manager have completed training in the protection of vulnerable adults from abuse. The policy on money and financial affairs for people who use the service includes advice on personal insurance and preclude staff involvement in assisting in the making of or benefiting from wills. This information is also reflected in the service users’ guide. A visiting relative said that ‘the service here is brilliant, first class’. ‘There are always plenty of staff on duty – and I come at all times of the day and evening’. ‘I am confident about my mothers care’. The relative confirmed they are aware of the complaints procedure and would have no hesitation in talking to manager should there be any concerns or complaints. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Breach House enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A tour of the home was conducted. Breach House is a large, detached property that was formerly a farmhouse. The premises have been adapted and extended as a residential care home for older people. The property is situated in a rural area in approximately two acres of ground at the end of a long driveway on the edge of the Belbroughton village. The property is accessible, comfortable, well maintained and provides a homely environment for the people who live there. Breach House is registered to provide personal care for a maximum of 26 people over the age of 65 years. People who use the service are Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 18 accommodated in single bedrooms on three floors. Twenty-four of the bedrooms have an en suite facility. A number of the bedrooms enjoy attractive views of the surrounding countryside. There is a passenger lift to enable people to access accommodation on the first and second floors more easily. There are two lounges, a dining room and a conservatory. The garden is attractive and well maintained and there is adequate car parking space near the front of the building. The rooms seen were furnished and decorated to a high standard and had also been personalised by the people who live there. People spoken to said they ‘liked their room’ and ‘liked the view from their windows’. People said they were ‘very happy here’, ‘staff are very good to me’, ‘I like it here’. The home is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Staff were observed wearing suitable protective clothing for the work they were doing, and confirmed that they were familiar with the procedures regarding the control of infection. Records show that staff have been given training in health and safety matters. Refurbishment to areas of the home has taken place since the previous inspection. The floor covering in the corridor has been replaced and the communal toilets have been fitted with door locks that ensure privacy but allow emergency access. Handrails have been provided in the corridors for people who are infirm or physically disabled. The repainting of the top floor bathroom is scheduled for this year. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 19 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, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Breach House. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at Breach House. EVIDENCE: Breach House has a committed and stable staff team. The manager said the staff team are very well motivated and work hard to improve the lives of the people who use the service. People commented that they were generally satisfied with the home and the staff. The manager states in the AQAA that there are ‘4 staff on duty in morning and 3 in afternoon and evening, 2 waking night staff’ on duty. This level of staffing was confirmed during the inspection visit and by a visiting relative. Breach House operates a recruitment policy and procedure to ensure that everyone completes an appropriate application form and that suitable references are obtained including one from their most recent employer. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 20 Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period. Recruitment records were seen for three members of staff. The records are well-maintained and contained copies of all required information and safety checks. Each file has a staff checklist to ensure all checks are completed. Copies of references were seen. Regular staff training is provided. Staff complete mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults. A record is maintained for all training undertaken at the home. People spoken to say they ‘feel safe’ and that staff look after them very well. ‘They are always doing training you know’. Recent staff training includes Dementia Care completed in November 2007. The manager states in the AQAA that there are plans for staff to attend bereavement training during the coming year. New staff attend a two-day induction course in Droitwich. An induction checklist was seen which is completed to make sure that staff cover all areas during their induction programme. This is followed by the ‘Skills for Care’ Induction programme. Each new member of staff is issued with an employees’ handbook, which refers to principles of care such as respect, dignity, choice and individuality. The deputy manager and two of the senior care assistants (days) have completed the NVQ level 2 and NVQ level 3 training. Two newly appointed senior care assistants from overseas have undertaken nurse training in their country of origin. The nurse training is regarded as the equivalent of at least NVQ level 2 training. Two senior care assistants (nights) and two care assistants (days) have also completed training to NVQ level 2. The service exceeds the required level of 50 of staff trained to NVQ level. The manager says there are plans to make sure this level of qualified staff is maintained and improved, which is an example of good practice. Staff appeared to be enthusiastic and well motivated, and confirmed that training is provided for them. They are also given the opportunity to share their views and opinions at staff meetings. Comments include ‘I really enjoy working here’ and ‘we have a good staff team, and ‘the manager is very supportive’. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 21 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, 35, 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well managed and staff receive the leadership and support they need. The Responsible Individual monitors the home in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Julie Head has many years experience working with older people. Julie is qualified to NVQ level 4 and has completed her Registered Managers’ Award (RMA). Julie regularly completes training relevant to her position as registered manager of Breach House, including first aid and vulnerable adults training. Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 22 Staff confirmed that the manager is approachable and supportive. People who use the service said that the manager was ‘very helpful’ and ‘always makes time to talk’. The manager confirmed that she receives regular support from the Providers. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI prior to the inspection visit. The need for a formal system for measuring how well Breach House succeeds in delivering a quality service where the results are audited and published annually were discussed. Evidence of progress was seen and the manager is to complete a report of the findings and produce an action plan for the coming year. This will include views obtained from people who use the service and stakeholders, weekly reports completed by the manager and sent to the provider, reports on monthly visits by provider, Breach House newsletters, completed policy reviews, and the report from an audit recently completed by the visiting PCT pharmacist. Worcestershire County Council as part of the ‘Having Your Say’ advocacy assessment has recently visited Breach House. Assessments of the service were completed and included looking at decisions people could make which affected their everyday life. The assessment was successful and presentation of the award certificate is pending. This award permits the service to use the ‘Having Your Say’ logo on their stationery. The report for a recent inspection by the Environmental Health department was seen. The service has been awarded a 4 star rating for the ‘knock on doors’ assessment. The manager confirmed that staff do not have any involvement in the financial affairs of people living at Breach House. The manager said that the money and accounts for people living at Breach House are audited every month with an accurate record maintained of any items handed over for safekeeping. Supervision of care staff includes all aspects of care practice, philosophy of care in the home and career development needs. Staff appraisals are completed annually, and staff records confirm this. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. The fire risk assessment has been reviewed with annual reviews planned. A record of the monthly emergency lighting checks is maintained in accordance with the recommendations of the Fire Safety Officer. Risk assessments are carried out and recorded for safe working practices including the security of the premises and food hygiene. The records relating Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 23 to accidents within the home are completed in full and accurately maintained. The registered manager and deputy manager have completed training in First Aid at Work (four day course). Breach House DS0000018495.V361156.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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Breach House DS0000018495.V361156.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. 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. 1. Refer to Standard OP9 Good Practice Recommendations Where the details of currently prescribed medication are listed in care plans the frequency of administration is abbreviated. It would be good practice to put an explanatory key at the top of the page where abbreviations are used. It would be good practice and help staff in their care practice to provide information on each medication and any possible side effects. 2. OP9 Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Breach House DS0000018495.V361156.R01.S.doc Version 5.2 Page 27 - 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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