Care Home: Briarvale Care Home

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What the care home does well What has improved since the last inspection? What the care home could do better: CARE HOME ADULTS 18-65 Briarvale Care Home 158 Ashby Road West Shepshed Loughborough Leicestershire LE12 9EE Lead Inspector Keith Charlton Unannounced Inspection 14th April 2008 02:05 Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Briarvale Care Home Address 158 Ashby Road West Shepshed Loughborough Leicestershire LE12 9EE 01509 829283 01509 829603 ruthwardhaugh@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Malcolm Wood Ms Ruth Wardhaugh Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To be able to admit one named person in category LD/PD (dual disability) as agreed with the previous registration authority. 5th September 2007 Date of last inspection Brief Description of the Service: Briarvale is registered to provide care for 10 people with learning disabilities. The accommodation consists of 10 single bedrooms, some with en suite facilities. There is a residents lounge on the ground floor and there is to be a activities room on the second floor. It is furnished and decorated to a generally good standard. There is a large garden and patio area to the rear where residents can sit out. The home is situated close to Shepshed town centre and local shops are within easy reach. Most residents attend local day centres. Fees typically range from £320 to £1050 per week - this information was provided on the day of the inspection. There are costs for extras - hairdressing, toiletries, holidays, transport etc. The Statement of Purpose, Service Users Guide and copy of the last Inspection Report is available for anyone to look at. Briarvale Care Home DS0000049403.V362288.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. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. There are only a small number of residents that can communicate their views. This was an unannounced Inspection. The Registered Manager was not on duty so other care staff on duty assisted with the inspection. Planning for the Inspection included looking at the last Inspection Report, the Annual Quality Assurance Assessment that the Registered Manager provided which gives information as to the services that are provided, looking at surveys from the recent Annual Service Review (surveys were not sent out again for this inspection as it was less that two months age since the ASR, and assessing any notifications of significant events sent to the Commission for Social Care Inspection by the home. There have been no complaints received regarding the home in the past year, or since the Registered Manager took over as Manager in 2005. Surveys were returned by eight residents and they were helped by staff to complete them. (It was recommended in the future that families or advocates assist residents so there is more independence in doing this). People living in the home told us that they are very satisfied living there - I know the staff will help me at all times. The staff are nice and I have some fun..I can talk to the staff..I happy living here. I get on well with all the staff. Staff surveys were returned by six staff. All testified to the high standard of care that is supplied to residents and the staff systems that are in place to ensure that this continues to be the case - Up to date training for staff..meets the individual and collective needs of the residents. Provides a safe place for service users to live offering choice, promoting independence and inclusion to an active social life. I am quite happy..with the support I get from the manager and my fellow staff. Surveys were returned from 7 relatives, all being very satisfied with the high standard of care: Briarvale creates a good family atmostphere. We are happy with Briarvales care service on all counts. The staff are extremely attentive to comments, suggestions and concerns. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 6 The Inspection took place between 14.05 and 18.55 and included a selected tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with two residents, three members of staff and the Deputy Manager, and with the Registered Manager on the phone the next day. What the service does well: What has improved since the last inspection? More staff training on residents care needs has been provided. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 7 The home’s Quality Assurance system has been improved by asking what other other parties – relatives, Social Workers, GPs etc think of the home’s services. Facilities have been improved by the replacement of worn furniture – e.g. dining room chairs and redecoration of two bedrooms and the kitchen. A generally high level of service continues to be provided. 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. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An assessment system to meet residents needs will be in place when the need arises. EVIDENCE: There has not been an admission since the Registered Manager took over as Registered Manager. There are Social Service Department assessments for current residents. The Registered Manager stated on the last inspection that she would refer to National Minimum Standard 2 when an assessment was needed for a prospective resident to ensure it contained full details of residents needs. The Annual Quality Assurance Assessment states that it would consider the suitability of any prospective client and the impact on other clients through discussions with clients and their relatives and provide the necessary paper work in a written and pictorial format, and discuss with exisiting clients regarding prospective clients to gain feedback and opinions. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are well met. EVIDENCE: The two residents briefly spoken with thought they were well looked after by staff. The inspector case tracked two care records, which again clearly demonstrated that residents changing needs are being monitored and supported. Records and observations of staff practice demonstrated that they make decisions about their lives and have independent life styles as much as possible, e.g. although residents are not able to go out on their own or self medicate a number of people can use the kitchen with staff supervision. Staff said residents can make decisions about their own lives wherever possible Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 11 e.g. choosing what clothes they want to wear, what food they want, what time to get up and go to bed, to clean their own bedrooms, to help out in domestic chores if they wish etc. They are asked their views on important issues in their meetings and these are recorded regarding food, holidays, outings etc. Individual plans contained details of the circumstances in which residents rights to make particular decisions may have to be limited, e.g. the need to accompany on trips outside because of the lack of road skills and Risk Assessments are in place to indicate what care the staff need to follow. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to have a fulfilling lifestyle. EVIDENCE: Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 13 Residents talked about going on holiday to Blackpool this year, which they were looking forward to. There was evidence of activities – arts and crafts, music and karaoke, snoozelum, entertainers, cooking, going out to activities – Colleges, discos, link up, leisure centre and local pubs etc. One resident had evidence on her Care Plan that she liked going swimming though the Registered Manager said she had not been able to pursue this lately due to health problems. Other residents were shown various leaflets for places they may like to visit. Another resident seemed content to look at photos in a magazine. Records showed that residents have been on trips and are asked where they want to go on holiday. Residents Meeting notes showed that they have been consulted and regular trips are planned in the future. Residents are supported in helping in the kitchen with supervision as necessary. Staff said that residents use places in the community including local shops, pubs, the park and leisure centre as well as attending specific groups for people with learning disabilities. There was evidence on file that residents religious needs are respected as to anyone wanting to go to church or temple, involvement in religious festivities – Diwali etc. Staff said residents could have their visitors to the home and there were no restrictions on visiting times and talked about the father of a resident visiting every week and taking his son out. Food records showed that residents were given a choice of food for each meal. Diets have regular supplies of fresh and frozen vegetables and fruit is always available. For the dinner observed there were three fresh/frozen vegetables and the staff member preparing the packed lunches for the following day was preparing different fruit segments, which showed a commitment to a healthy diet. A resident is provided with a vegan meal, as per her cultural background. She also has a diet and exercise programme in her Care Plan. The meal tasted was good in terms of the mashed potato and vegetables but the stewed beef was tough and difficult to chew. This issue needs to be reviewed. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive generally good personal support with their physical and emotional health needs being met in most circumstances. EVIDENCE: The very comprehensive Clinical Records folder is still kept which details all medical appointments and check ups on an individual basis - from nurses, GPs, dentist, chiropodist, speech and language therapist etc. Through observation, discussion and records, it was demonstrated that clients receive support in the way they prefer and require it. Care Plans indicate all aspects of health care needs are covered – e.g. management of dementia, personal care, monitoring weight, communication, social skills, work and play etc. It was seen that a resident with dementia had signing to her bedroom door to help her see where her bedroom was. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 15 There is a resident who has frequent falls owing to having regular seizures, reflected in a number of entries in Accident Records. There was evidence of potentially serious head injury for some of these falls. Staff need to seek advice from Medical Services on the course of action to follow if a residents has a head injury, as this was not always found to be the case on some occasions. The Registered Manager said this would be followed up. Such incidents where residents receive hospital treatment need to be reported to the Commission for Social Care Inspection under the Regulation 37 procedure so that the Commission can monitor these situations. No resident was able to self medicate. Staff said that those who issue medication have all been trained and a new staff member said she was currently working on the distance learning information leading to a medication qualification. Medication records were checked and found to be generally good with only a small number of gaps, which the Registered Manager needs to follow up. Medication is securely locked away. The Annual Quality Assurance Assessment states that the home has comprehensive clinical and daily records on all clients which highlight areas of initial concern by staff through to appointments, treatment ( if any) to outcomes and recovery. They include all areas of general health including well person checks. Clients are given the oppurtunity to discuss any treatments or appointments with staff or advocates and make informed decisions about what they wish to happen or not. Any personal issue is treated in the strictist confidence. All clients are given the choice of what they wish to wear and are helped to make weather appropriate choices. Care plans are detailed and regualarly updated as needed. No clients at Briarvale self administer medication. Each person has a calender of appointments for routine and specialist checks. Ensuring clients are aware of there own health needs and can make informed choices about outcomes and have well woman and well man checks if they choose. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents welfare is protected by the procedures of the home. Residents views are listened to and acted upon. EVIDENCE: The Complaints Book indicated that there have been no complaints made since the Registered Manager took. The Commission for Social Care Inspection has also received no complaints regarding the service. The Complaints Procedure seen by the inspector reflects the National Minimum Standard in that it stated that any complaints would be properly followed up, though it now needs to be altered to indicate that the local Social Service Department in now the Lead Agency for dealing with complaints regarding residents care. The Registered Manager said this would be followed up. There are residents meetings held where all residents are invited to attend and share their views about the home. A record of these meetings is available for staff to refer to. Staff members were asked about their understanding whistle blowing procedures, and demonstrated a generally good understanding of the protection of residents from abuse, though were not aware of all the contact Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 17 details of all relevant outside Agencies. The Registered Manager said this issue would be put in place. The Annual Quality Assurance Assessment states that the Complaints folder is accessible to all clients, relatives etc. Also suggestions for improvement. Clients and relatives are informed of the complaints folder during meetings to discuss Commission for the homes inspection reports. There are bi annual, informal meetings with relatives, involving the owner, where any concerns or issues can be raised. The Complaints folder could be more user friendly. The complaints folder has been updated and a suggestions form added for individuals to fill out if they wish to make suggestions about how the service can be improved. Residents are asked at client meetings if they have any concerns or complaints and informed they can discuss any issues in private if they wish. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a generally homely and comfortable environment, and standards of hygiene are satisfactory. EVIDENCE: Residents said that they liked their bedrooms and they could have their things in them. At the time of the inspection building works were underway to create two adapted bedrooms for physically disabled residents. This type of work needs to be agreed with the Commission for Social Care Inspection if it occurs in the future or facilities may need to revert to original use if it does not follow National Minimum Standards. There is now an accessible wheelchair friendly entrance to the home. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 19 The inspector looked at some of the bedrooms of residents and the communal area. Observations of the bedrooms demonstrated that décor in residents bedrooms suit their needs and lifestyles – a bedroom was recently decorated in the style of a resident’s choosing in that it had a Dr. Who theme. Standards of cleanliness in the bedrooms were satisfactory apart from odour in one bedroom with a stained carpet. The hallway carpet was also stained. Wallpaper had come off the wall in one bedroom and a bathroom. The staff member said the Registered Manager and Registered Provider were following this up. The Registered Manager said these issues would be put in place. The communal lounge/dining room areas have been decorated to a generally satisfactory standard though appeared in need of being updated as they looked worn and some bedrooms were in need of redecoration. New dining furniture had been bought. The Annual Quality Assurance Assessment stated that there is a House keeper Monday to Friday to clean all the main areas of the home. Personal living spaces are kept clean and maintained as and when necessary. Repairs are done in a timely manner. The home follows a cleaning rota each day and night to ensure all tasks are completed. The home is checked on a daily basis by staff on duty who will highlight to seniors any problems that may have arisen so they can be dealt with as soon as possible. Gloves and plastic disposible aprons are provided for all staff to use. Anti bacterial hand wash and alcohol gel hand wash is freely available for staff to use in wash rooms. Two clients have the use of commodes in their bedrooms. There are plans to improve some furniture in main living areas. Staff have done training in infection control and customer care and staff are to do Food Hygiene training in the next month. First Aid training is planned for May 2008. There is wheelchair access to outdoor facilities. A room on the first floor is to be used as a independent living skills area/ rec room. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated staff group. EVIDENCE: The residents spoken with said they were happy with staff. Staffing levels during the course of the inspection appeared to meet residents needs. There is normally three care staff on duty when residents are in the home, with a staff member also employed to carry out day care activities. These are higher than normal as one resident needs have one to one care and two to one care when he goes out. There is a waking staff member of night staff on duty at night and two staff members on call. There is a domestic worker, which means care staff can concentrate more on care work. The only issues raised in staff surveys were that there were usually enough staff on duty, which was supported by a relative’s comments, and that the Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 21 home could involve residents more in decision making. These comments have been considered by management. There are to be new staff employed when more residents are admitted into the home. One relative said: The staff are extremely attentive to comments, suggestions and concerns. Staff members were spoken to and had a good knowledge of residents care needs as they had been directed to read Care Plans by the Registered Manager and were again committed to providing a good service to residents. Staff were observed to be working with residents mostly in a positive and friendly way and considerate in their dealings with residents needing personal support. There were a small number of occasions where good care was not in place where a staff tried to get a resident to be quiet when she was talking a lot, where bedroom doors were not knocked on before entering, and where a loud personal mobile went off on a number of occasions, therefore not respecting residents privacy and dignity. The Registered Manager said this issue would be followed up. Staff records were inspected and found to have all the necessary statutory checks. The Registered Manager is currently undertaking the Registered Managers Award training. There is over fifty of staff with a National Vocational Qualification level 2 qualification, which meets the National Minimum Standard. A staff member said she had been encouraged to carry on her National Vocational Qualification level 2 training from her last job. There was evidence on file that staff have had training in a wide range of topics – the Person Centred Planning system which identifies service users individual needs, Health and Safety, Pressure Care, Insulin Administration, Equality and Diversity and Moving and Handling. Training records are kept within individual staff files. The Registered Manager has an in house induction programme and evidence that training followed nationally recognised training. The Annual Quality Assurance Assessment stated that Briarvale has a long standing core of staff who know and understand the clients changing needs very well. Staff turn over is low and on average employ approximately two to three new staff per year which makes Briarvale a very stable environment for the clients who as a result receive good continuety of care.Staff training is ongoing and geared to the changing needs of the clients. We currently employ 12 staff . Recruitment of new staff is timely and in accordence with National Minimum Standards. Applicants are encouraged to visit the home for an informal look around which clients may wish to take part in. Clients are also asked if they wish to sit in at the interview stage so they can give their opinion of each candidate. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 22 Staff must have two satisfactory references and a full Criminal Records Bureau check. Staff turn over. Sickness and absents records. The aim is to get all staff up to NVQ/2 or above. There is a good training program with regular staff meetings and staff supervisons. Use of agency staff is sometimes necessary but is minimal and one agency only is used to help with continuity of care. Staff have taken part in training in various topics: Food Hygiene, First Aid, Buccal Midazolam and epilepsy awareness, Fire awareness,Introducing communication, Dementia awareness, Safe handling of medication, Abuse training and Customer care. One staff member is working towards her NVQ/2 and another has just finished her last unit. Another is working through her NVQ/3. There are eight staff working towards or completed National Vocational Qualification level 2 or above. New staff are to be employed to cater for the needs of new clients as necessary. Training to be continued in areas that need updating and meet clients needs. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the proactive management of the home. EVIDENCE: Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 24 Staff spoke highly of how the Registered Manager runs the home. The Registered Manager has now completed her Registered Managers Award training. The Staff Meeting notes seen are detailed and comprehensive and focus on ensuring staff are aware of residents changing care needs. The Quality Assurance survey to find out what people think of the way the home is run now includes a wide range of parties, including relatives and even the hairdresser and taxi driver. Staff members were asked as to the fire procedure and were generally aware of this though missed out the first step to take. The Registered Manager said this issue would be put in place. Fire records showed that regular testing of fire bells (though this was not always on the required weekly basis) and emergency lighting was in place and there are regular fire drills. The fire risk assessment is in place. There is a fire risk assessment to identify and deal with fire risks. The Registered Manager has arranged the fitting of radiator covers as assessed as needed to protect residents from heat injuries. Where they have not been fitted the Risk Assessment states that risk is low, as valves have been fitted to deal with hot radiator surfaces. Hot water temperature charts were in place though they did not always state what action was needed if temperatures were above the National Minimum Standard. The Registered Manager is to review this. Health and Safety Policies and Procedures are in place and staff said they are encouraged to read them. The Annual Quality Assurance Assessment states that the Registered Manager completed the Registered Managers Award training in early 2007 and is awaiting the certificate. Client meetings are are now held every two/three months. The views of clients and relatives are sought annually through a short questionnare and during bi annual summer and christmas get togethers. Person Centred Planning - a system which identifies residents needs and reviews also give the oppurtunity to seek the views of clients about likes and dislikes. Clients are happy to express their views to staff at any given time and highlight any problems to staff. Client meetings are to be more user friendly and relatives involved to help with feedback and suggestions and ideas. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 4 X 3 X X 3 X Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA19 Regulation 13 Requirement Potentially serious accidents to residents need to be reported to Medical Services to ensure health needs are fully covered. Timescale for action 14/05/08 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. 2. 3. 4. Refer to Standard YA17 YA24 YA30 YA32 Good Practice Recommendations The meat supply needs to be reviewed to ensure meat is not tough. Some décor and carpets are in need of renewing. Odours need to be swiftly dealt with. Staff must always respect the dignity and privacy of residents. Briarvale Care Home DS0000049403.V362288.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Briarvale Care Home DS0000049403.V362288.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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