Care Home: Briarmede

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What the care home does well Briarmede presents as a very warm, caring and friendly care home and residents appeared relaxed and comfortable with the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents` individual care needs and the level of support required. During our visit staff were observed spending a great deal of time with residents, either on an individual basis or within a group. Care was seen to be given in a discrete, sensitive manner and staff were patient and gentle in their approach. Feedback from residents was very good; comments regarding the service included: "just ask the staff they are always there"; "Staff are excellent" and "The care is really good". Prior to admission the manager assesses residents` health and social needs. Information collected is then used to form the basis for the plan of care. Assessment documentation seen had been completed to a good standard and included key areas regarding the residents` health and general well being. Care files were organised, the information easy to read and care plans identified the relevant care and support required. Attention is paid to recording basic needs such as dental, optical, hearing and foot care. Lots of different types of activities were arranged, both in the home and out in the community. The physical accommodation is of a good standard, with appropriate aids and adaptations available for the residents. The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Seven staff were spoken with and comments included were: "The home gives good training"; "The home looks after the residents well" and "We feel we provide excellent individual care for each resident". The manager was experienced and ran the home well. She made sure she checked out staff before they started working at the home and gave them training and support to make sure they did the job to the best of their ability. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of `good practice`, particularly in relation to continuous improvement, staff training, resident satisfaction and quality assurance. What has improved since the last inspection? All of the requirements and recommendations from our last inspection have been met. All of the care plans had been rewritten and now give a full picture of what each person needed help and support with in order to have their needs met. They are more person centred and include information about people`s preferred routines and likes and dislikes in relation to their daily lives. Improvements in the way medication was given out were noted. The manager makes sure she follows the home`s safeguarding policy and would notify Social Services as soon as any concerns were noted in this area. New staff do not start work at the home until two satisfactory references have been obtained. This helps to ensure that the right people are being employed to care for the people living at the home. All new staff have an induction training programme, that meets Skills for Care Common Induction Standards. This ensures that new staff get all the training needed to help them care safely for the people they were looking after. The way residents` finances were recorded have been revised and those accounts checked provided accurate and up to date information in respect of personal finances held by the home for residents. An effective system for checking out the quality of care and the services provided for the residents is now in place. CARE HOMES FOR OLDER PEOPLE Briarmede 426/428 Rochdale Road Middleton Manchester Greater Manchester M24 2QW Lead Inspector Bernard Tracey Unannounced Inspection 25th September 2008 07:50 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 Briarmede DS0000025466.V371003.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. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briarmede Address 426/428 Rochdale Road Middleton Manchester Greater Manchester M24 2QW 0161 653 2247 F/P 0161 653 2247 briarmedecarehome@hotmail.co.uk 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) Adrian Peter Riley Mrs Patricia Riley Adrian Peter Riley Mrs Tina Riley Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 32 service users, both male and female to include: up to 32 service users in the category of OP (Older People) The service should employ a suitably experienced and qualified manager who is registered with the Commission for Social Care Inspection. 13th December 2007 Date of last inspection Brief Description of the Service: Briarmede is an adapted building offering 24 hour personal care to 32 older people. The home has a total of 24 single and four double bedrooms. Six of the single rooms have en-suite facilities. Bedrooms are located on both the ground and first floors. A passenger lift is provided. The home is situated on the main Middleton to Rochdale Road. Access to the home is via one step into the front door. Public transport passes on a regular basis and the home is also in easy reach of the motorway network. A car park is provided to the rear of the home. It offers parking for approximately 12 cars and is accessed by one of two entrances. The home’s Service User Guide advised residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report was available in the reception hall. At the time of this inspection weekly fees ranged upwards from £347.71p £362.71p per week, dependent upon whether the room was shared or had ensuite facilities. Additional charges were for hairdressing, chiropody, newspapers, toiletries and outings. Briarmede DS0000025466.V371003.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 stars. This means the people who use this service experience excellent quality outcomes. We (the Commission of Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. The staff at the home did not know the visit was going to take place. Some weeks before our planned visit the manager was asked to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA), telling us what they thought they did well, what they need to do better and what they have improved upon. This helps us to determine if the management of the home see the service they provide the same way that we do. We felt this form was filled in honestly and that a lot of time and effort had been given to filling it in. Where appropriate, the comments have been included in the report. We spent six hours at the home over one day. During this time, we looked at care and medicine records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. A tour of the building was undertaken and time was spent looking at records regarding safety in the home. We also examined files that contained information about how the staff were recruited for their jobs, as well as records about staff training. We spent time speaking to eight residents and one relative who was there during our visit, as well as speaking to seven staff, the manager and the joint owner. We have received one anonymous complaint about the service since our last inspection but, in discussion with the manager and owner, decided that the complaint could not be upheld. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 6 What the service does well: Briarmede presents as a very warm, caring and friendly care home and residents appeared relaxed and comfortable with the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents’ individual care needs and the level of support required. During our visit staff were observed spending a great deal of time with residents, either on an individual basis or within a group. Care was seen to be given in a discrete, sensitive manner and staff were patient and gentle in their approach. Feedback from residents was very good; comments regarding the service included: “just ask the staff they are always there”; “Staff are excellent” and “The care is really good”. Prior to admission the manager assesses residents’ health and social needs. Information collected is then used to form the basis for the plan of care. Assessment documentation seen had been completed to a good standard and included key areas regarding the residents’ health and general well being. Care files were organised, the information easy to read and care plans identified the relevant care and support required. Attention is paid to recording basic needs such as dental, optical, hearing and foot care. Lots of different types of activities were arranged, both in the home and out in the community. The physical accommodation is of a good standard, with appropriate aids and adaptations available for the residents. The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Seven staff were spoken with and comments included were: “The home gives good training”; “The home looks after the residents well” and “We feel we provide excellent individual care for each resident”. The manager was experienced and ran the home well. She made sure she checked out staff before they started working at the home and gave them training and support to make sure they did the job to the best of their ability. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘good practice’, particularly in relation to continuous improvement, staff training, resident satisfaction and quality assurance. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 7 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. Briarmede DS0000025466.V371003.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 Briarmede DS0000025466.V371003.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 (Standard 6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Detailed assessments are undertaken before people come into to the home so they can feel confident that their needs can be met. EVIDENCE: The admission arrangements for new residents were very thorough. This ensured that the home would be a suitable placement for that person and would be able to meet their assessed needs. Initial enquiries were recorded and followed up by a visit to the individual, either in their own home or, more commonly, in hospital, to complete a detailed assessment of their needs. The manager liaises closely with family members and any health care professionals involved with the prospective resident. This helped the manager to build up a full picture of the person’s needs. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 10 The assessment included personal and healthcare needs, as well as social care and behavioural needs. The manager generally conducted pre-admission assessments. All residents had a contract in their personal file, either signed by the individual or their representative. Briarmede DS0000025466.V371003.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 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Care plans and care practices ensure that the residents’ needs are met in a very safe, caring and dignified way. EVIDENCE: Significant progress has been made in relation to the care plan documentation and methods of recording how the needs of the residents will be met. Each resident had a detailed up to date and individual plan of care, covering all aspects of personal, health and social care needs. These are based on the preadmission assessment and other specialist assessments in place, including social work assessments. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 12 The care files of three residents were looked at. Each of these files contained a detailed and comprehensive care needs assessment that describes the help that the resident needs with everyday living, including health, personal and social care needs. All of these documents had been reviewed at monthly intervals using a separate document that described any changes in the way that the resident needed to be looked after. Any areas of risk for the resident were highlighted along with the planned action to reduce that risk. These included an up to date manual handling assessment and a nutritional assessment tool that is used at the time of the resident’s admission to the home and then afterwards as required. Nutritional wellbeing is also assessed by direct observation and by regular and up to date weight checks. Skin condition is also checked by direct observation with a pressure area care plan being implemented if required. Care plans demonstrated that residents’ personal choices and preferences had been taken into account by staff around care delivery, such as who liked a bath and who would prefer a shower. Personal care was provided privately in bedrooms or bathrooms, and door locks or engaged signs were used. One resident told us that the staff were “Very good indeed. Always there when needed. All staff very pleasant supportive and helpful”. Residents wore their own clothes and were dressed appropriately for the weather and their activity. Hair care, nail and teeth care and shaving had been attended to. Healthcare arrangements were also good. Residents had good access to their local doctor and the district nursing service visited the home regularly. The management of medicines in the home was safe and served to protect residents from harm and ensure they benefited from the medicines prescribed for them. Staff were knowledgeable about residents’ medicines and understood about monitoring for side effects and adverse reactions. The home works to an efficient Medication Policy supported by procedures and practice guidelines that include guidance for the self-administration of medicines. One resident was dealing with her own medicines at the time of this visit. Staff follow robust systems to make sure that medication records are fully completed, contain required entries and are signed by appropriate staff. Staff who have responsibility for giving out medicines have been given the necessary training for this task, which was updated in 2008. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 13 Residents spoken with were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity were respected at all times. This was also observed during our visit. The care assistants interviewed were able to give good examples of how they promoted privacy and dignity in their daily care routines, for example, knocking on bedroom doors before entering. The residents said that the staff had a “kind and considerate” manner and that the staff spoke to them in a “civil and courteous” way. Briarmede DS0000025466.V371003.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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents are able to enjoy a full and stimulating lifestyle with a variety of opportunities to choose from. EVIDENCE: The range of leisure activities available in the home was varied, reflecting the diversity of residents and their social, intellectual and physical capacities. The home has a dedicated activity co-ordinator who organises events and activities within the home, as well as trips out to various places of interest. The programme of activities was displayed in the reception area and in other strategic places throughout the home, so that residents were aware of what was ‘going on’. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 15 We met with the activity co-ordinator during our visit to the home. She has sought the views of residents and considered their varied interests and abilities when planning the routines of daily living and arranging activities. The routines, activities and plans are resident focussed, regularly reviewed and can be quickly changed to meet individual residents’ needs. Each resident has their own activities and interest assessment completed and their interests are recorded and a programme agreed to reflect their personal preferences. Links with the community were good and valued the role which relatives and friends continued to play in the lives of residents. On the day of our visit several residents their relatives and staff members were going out to the circus. The manager and staff are aware of promoting equality and diversity and encourage the residents to develop a lifestyle and interests that are individual to them. Residents benefited from being able to exercise choice and control over their lives. Residents are actively supported in pursuing their spiritual beliefs and practices. Some residents choose to take part in group activities, such as going for bar meals, walks, the garden centre, while others have chosen to pursue their own interests within the home. Residents we spoke to said they enjoyed the food and that they receive enough to eat and drink. Comments made in respect of the meals in the home were “the food is excellent and varied”; “We are always offered an alternative if we do not fancy what’s on the menu”. We observed staff being attentive during the lunchtime period, asking if people had finished their meal before they removed their plate, asking if they wished for some more and offering a choice of starter, main meal and dessert. The dining tables were set appropriately – tablecloths, cutlery, serviettes and jugs of water. Briarmede DS0000025466.V371003.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There is a clear complaints procedure and residents and their families know action will be taken to resolve their concerns. Staff have a good knowledge and understanding of Adult Protection issues which safeguard residents from abuse. EVIDENCE: There is a clear complaints procedure, which told people how and who to make any complaint to. The procedure was well advertised to relatives and visitors to the home. Records showed that any complaints made had been fully investigated and responded to appropriately. A staff member said, “If a resident wanted to make a complaint, I would go to the manager and give her the information”. A visiting relative said, if necessary, “I would talk with the Manager or any of the staff as I feel they would act on what I was concerned about” but said that matters were usually dealt with straight away, so there was no need to complain One complaint has been made directly to the Commission for Social Care Inspection. The details were discussed with the manager on our visit and concluded that the complaint was not substantiated. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 17 All staff have undertaken training in relation to the Protection of Vulnerable Adults. The home also has an abuse policy and whistle blowing procedure. The staff training record evidenced abuse awareness training for a number of staff and staff interviewed had an understanding of how to report an alleged incident. The home has a copy of the Rochdale Guide for the Protection of Vulnerable Adults. Briarmede DS0000025466.V371003.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. It is a well maintained, comfortable and attractive home in which to live and meets all the assessed needs of the residents. EVIDENCE: The home is well maintained, decorated to a high standard and was clean and tidy during the site visit. A partial tour of the building was undertaken, two bathrooms, a shower room and six bedrooms were viewed. The bathrooms were clean and tidy and hot water temperatures are recorded each month to ensure the hot water is delivered to a safe temperature. Bedrooms viewed had individual personal items, were homely and comfortable. A resident said, “I have everything I need, including some of my own furniture.” Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 19 Bedrooms have door locks and a call system with a hand held buzzer to call for assistance. The home is equipped with comfortable furniture, fittings and electrical equipment, including televisions and CD players. . There is a well equipped laundry and there was evidence of gloves and aprons for staff use. Infection control training is given to staff and infection control policies are available. There are appropriate aids and equipment, such as assisted bathing facilities, handrails and a passenger lift in place. There are sufficient housekeeping staff and on the day of this visit the home was clean, fresh and hygienic. Policies and procedures are in place to promote a high standard of cleanliness and hygiene. Briarmede DS0000025466.V371003.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 & 30 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. The staff team had collective skills training and expertise to undertake their roles effectively and good recruitment and selection procedures were in place to ensure that the residents were protected. EVIDENCE: Staffing levels within the home were seen to meet the needs of residents. Care staff undertook their duties in a friendly and caring manner, promptly supporting residents’ when needed. Residents confirmed that staff were always respectful and met their needs competently. In the main, residents were satisfied with the support they were given and described staff as “nice people”, “lovely”, “find time to listen” and “good fun and very efficient”. A relative we spoke with said “the staff give excellent care for mum and me in the most thoughtful manner” Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 21 Three staff files were viewed with regard to recruitment practices and these contained all of the necessary checks to protect the residents. Staff had completed a job application form and two references had been obtained. Staff files contained a POVA Protection of Vulnerable Adult check and Criminal Record Bureau disclosure at enhanced level. The necessary checks are in place prior to staff commencing work and the interviewer completes an interview checklist. Individual staff training records provided a clear summary of both induction and ongoing training. This was extensive and wide ranging, with mandatory courses, i.e., moving and handling, medication, fire safety and first aid. Specialist training included care planning, risk assessment, mental health and Dementia. This training package was confirmed by the manager and was identified in the written AQAA she had provided us with. Similarly, staff who were interviewed confirmed that training was available, that they were encouraged to attend and that it gave them appropriate competencies to meet the needs of the residents. A staff member commented, “the training is excellent here”. Briarmede DS0000025466.V371003.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, 35 & 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 well managed and practices within the home ensure the safety and wellbeing of the residents and staff. EVIDENCE: The manager has the required qualifications and experience, and is competent to run the home. There is a strong emphasis of being open and transparent in all areas of running of the home. The manager and staff work hard to make sure that everyone feels they are included in decision-making and feel valued as an individual. Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 23 There is a good system in place to gather staff, residents and relatives’ views through regular meetings and satisfaction questionnaires as part of the monitoring of quality. The manager achieves this by sending out surveys to residents and relatives asking for their views on the friendliness of the staff, the care provided, the laundry service, the meals provided, social activities and the cleanliness of the home. They have recently been awarded the Investors In people Award. Staff spoken to had a clear understanding of their role and what was expected of them. Documentation was examined that confirmed that staff received regular supervision and annual appraisal. Residents and visitors spoke well of the management team and the care and support that they give. During our visit we were able to witness their approach to the residents and staff and confirm the comments made. Comments made included: Excellent management. There is an open door policy. All of the staff have a good team spirit. Relevant training sessions are provided. Good induction and support for newcomers. Up-to-date policies and procedures are available. I have worked in other care homes but the manager here is excellent and the best I have seen. Information provided by the manager in the AQAA and examination of the records, confirmed that all safety equipment is regularly serviced. We confirmed this through examining a random sample. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. The system for the safekeeping of residents’ finances was good. Individual records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any “spending money” for their relative. The Annual Quality Assurance Assessment (AQAA) requested by the Commission was returned in time and was completed with a high degree of detail. Within this document the owner and manager had made us aware of how the were operating the home and also identified how they felt they could improve. Briarmede DS0000025466.V371003.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 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 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Briarmede DS0000025466.V371003.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. Refer to Standard Good Practice Recommendations Briarmede DS0000025466.V371003.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection NW Regional Office Unit 1, 3rd Floor Tustin Court Port Way 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 Briarmede DS0000025466.V371003.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!