Care Home: Brigstock House

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What the care home does well What has improved since the last inspection? Criminal Record Bureau checks have been updated to ensure they are all specific to the setting. This was needed because a CRB from a different employer may not have all the required checks on it, regardless of whether it is an enhanced check or not.Where the home manages a service users money, financial records and care plans now clarify when change from a service user`s spending money is kept by themselves and will therefore not fully tally with receipts records. This was needed so that all the service users` money can be fully accounted for. What the care home could do better: Each resident should be offered a seven-day holiday paid for by the home as a part of the contracted price. This would facilitate more funding and additional holidays for residents that they do not have to pay for. It is however recognised that the home has done all it can to bring this to the attention of the placing and funding authorities and any further progress is now in their hands. In addition, the home has contributed towards the cost of service users` holidays from its own funds which facilitates more holidays. CARE HOME ADULTS 18-65 Brigstock House 57 Brigstock Road Thornton Heath Croydon Surrey CR7 7JH Lead Inspector Barry Khabbazi Key Unannounced Inspection 22nd October 1 November 2007 08:30 Brigstock House DS0000025758.V353001.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 Brigstock House DS0000025758.V353001.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. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brigstock House Address 57 Brigstock Road Thornton Heath Croydon Surrey CR7 7JH 020 8665 6369 020 8664 8254 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) www.bdcsupportingservices.co.uk Mr Cass Mohamedally Mrs Patricia Mohamedally Mrs Kay Jardine Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2007 Brief Description of the Service: Brigstock House is a care home registered for eight adults with a learning disability. The home currently provides a service to a service user group with a wide range of needs including complex needs. Brigstock House is one of three similar homes owned by Mr and Mrs Mohamedally. Brigstock House is staffed throughout the day and with staff who sleep on the premises at night. Each service user has an allocated key worker to support them to identify and meet needs. The detached property is keeping with the other houses on the road. There are 8 single bedrooms. There is a communal lounge, a dining room and a kitchen. Other facilities include a laundry, staff sleeping in room and staff office. There is an established rear garden with a lawn, mature trees and bushes, a patio area. Access to the premises from the garden and front of the house are via stairs only. This home is currently not suitable for people with physical impairments affecting mobility. The home is located in Thornton Heath, within easy access by public transport and local shops. Residents of the home attend day centres on weekdays and the home has its own car. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The management of this home is currently in the process of changing and those changes will be fully reflected in the next report once the current manager has been de-registered and the new manager has been registered. This report is therefore based on the original manager still being officially the current registered manager. No negative outcomes of this change process were observed at this inspection. Both previous requirements have been met and no new requirements were necessary at this time. The key Standards identified throughout this report were assessed at this inspection. This inspection also focussed on following up on previous requirements and recommendations, and any new issues arising. This inspection was unannounced and started early in the day to allow the residents to be met, before they went to their day activities. As the manager may not have been available at the unannounced inspection, to provide information regarding some key standards {for example staff recruitment files}, a separate meeting with the manager was also arranged. The manager was interviewed, time was spent with the service users, and records, policies, care plans, and the building were also examined. The home was found to be generally well run. This home currently meets {and exceeds in some cases} all of the National Minimum Standards and has demonstrated many areas of good practice. There were no previous unmet requirements remaining and there are no new requirements in this report. During the inspection, service users talked about recent activities and outings they had attended and responded positively to questions about the quality of the meals. Where communication was limited by the service user’s disability, those service users appeared relaxed and contented. Staff were seen to be supportive and responsive to service users needs. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Criminal Record Bureau checks have been updated to ensure they are all specific to the setting. This was needed because a CRB from a different employer may not have all the required checks on it, regardless of whether it is an enhanced check or not. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 7 Where the home manages a service users money, financial records and care plans now clarify when change from a service user’s spending money is kept by themselves and will therefore not fully tally with receipts records. This was needed so that all the service users’ money can be fully accounted for. 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. Brigstock House DS0000025758.V353001.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 Brigstock House DS0000025758.V353001.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): Standard 2: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed before they start at the home to ensure that all needs are known. EVIDENCE: There had been no new service users since the last inspection to allow this standard to be re-assessed at this time. However, the newest service user’s file was examined at a previous inspection and these contained the care management assessment and care plan as required by this Standard. In addition the home has completed its own assessment of need. Evidence of good practice presented: . Standard 2.3 only requires internal assessments for privately funded service users. Although the home does not have privately funded service users, it still produces an internal assessment for all its potential new admissions, including the most recent referral. This creates a higher level of knowledge of the needs of a new service user. Brigstock House DS0000025758.V353001.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): Standards 6, 7, 8, and 9: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care record all needs and are regularly updated which means that the residents can be assured that there changing needs can be met. Service users are supported to make decisions about their lives which enhances their independence and dignity. Service users are consulted on all aspects of life in the home and these views are implemented where appropriate. Risk assessments contain all the information required as including this information could reduce unnecessary restrictions of liberty for the service users. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 11 EVIDENCE: The service users each have a care plan generated from the comprehensive assessment completed by the care manager. All of a service user’s needs, how they are to be met and by whom, are recorded in their care plan or individual plan. Care plans sampled also refer to cultural or religious needs. These were either recorded or a record that the service user has no identified cultural or religious needs was present. Care plans sampled had also been reviewed at least twice a year as required. In addition new good practice has been identified with monthly reviews also occurring. The review format is currently changing to involve the service users more. The service users’ preferences for how their support with personal care is carried out is now being recorded so that staff can carry out this support in the manner that service users prefer. Guidance regarding holistic care planning has been given to staff in a team meeting. Plans of care contain written cues covering all the elements of Standard 2.2. This facilitates a more holistic plan of care and assists the home to evidence that all a service user’s needs are recorded, even if the section records ’no identified needs’. Choices are only limited through involving the service user and relatives where appropriate. This is always through a risk assessment process and recorded in the service user’s file. The service users each have a cash box for their personal allowance. When money is withdrawn from the cash box, the balance is checked and it has to be signed for by staff members. The last inspection report contained the following requirement: Where the home manages a service user’s money, financial records and care plans must clarify when change from a service user’s spending money is kept by themselves and will therefore not fully tally with receipts records. Records for this are now recorded in care plans to clarify where any change is held. This requirement is now met. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 12 The service users are offered the opportunity to participate in the day to day running of the home and to contribute to the development and review of policies and services through accessible documentation including pictorial versions, regular house meetings and individual discussions with their key workers, and involvement in the annual development plan for the home. See also the service user inspection pilot recorded in the last inspection report for further supporting evidence. Service user inclusion, involvement and service user consultation are areas of good practice for this home, and the service users’ familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded in the last report. This is reflected by Standard 8 – ‘service user consultation and participation in the running of the home’, being exceeded. Risk assessments are in place for all areas where restraints or restrictions of liberty are pre-planned. These contain all the information required under Standard 9, including what training or other options have been explored before a restraint or restriction of liberty is applied. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 13 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): Standards; 12 13, 14, 15, 16, and 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 be part of the local community and are able to take part in appropriate activities and holidays. This promotes inclusion and quality of life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents’ rights are respected and responsibilities recognised which enhances their independence,self worth and dignity. The food provided is sufficient in quantity, and it is sufficiently nutritious which is important to ensure good health. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 14 EVIDENCE: Service users’ attend college where they undertake courses which have in the past included self advocacy courses such as speaking up for yourself, and computers and cooking. The activities at the home’s day centre have been observed and included independent living skills. Each service user is offered a day each week where they are supported by staff to meet specific needs away from a structured day centre or college. These needs include community living and participation skills and practical life skills. One service user is provided with a fridge and kettle in their room to support independence. Diversity in spiritual activities is supported. Some service users attend church and one attends a temple. Basic money awareness training occurs for some of the service users during shopping trips. One service user has ‘work experience’ in maintenance and one service user is currently doing work experience. The home provides its own day centre in Thornton Heath, which service users attend, and other day centres are accessed. Activities at the home’s own daycentre include Adult Education and leisure activities. Staff help the service users with benefit problems and refer on as required. Although all staff are involved in supporting recreation, one member of staff has been identified as the recreation officer and has specific responsibilities in this area. Accessing the local community is assisted by the home having its own car. The local college, cinema, pubs, libraries, leisure centres, bowling alley, and shops are accessed. A number of service users were observed accessing the community during the inspection. Staff are available to support service users while accessing the community. This is not needed for all the service users as some access the community independently. All service users are on the electoral register, and support has been offered to the service users to access the polling stations and engage in their civic rights in the past. The last inspection report contained the following recommendation: Each resident should be offered a seven-day holiday paid for by the home as a part of the contracted price. This has not occurred. However, it is recognised that the home has done all it can to bring this to the attention of the placing authorities and any further progress is now in their hands. Evidence of good practice presented: . Standard 14, The home has contributed towards the cost of service users’ holidays from its own funds which facilitates more holidays. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 15 Family and friends are made aware of the home’s visiting policy and there are no restrictions regarding when family or friends can visit. Service users also visit their relatives. One service user talked about their relative visiting and then them both going out shopping. Service users’ choices are respected and they can choose whom to, or not to, see. Service users have the opportunity to make friends who do not necessarily have their disability, through community use and church contact. Evidence was provided to confirm the following: staff have information and health training to support service users in making appropriate and informed decisions where they wish to develop close relationships, staff ensure that this was mutually welcomed, where this is not welcomed or appropriate staff do take appropriate action to protect the service user. Health and relationship training has been provided where identified as needed. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. At the weekends there is more flexibility with breakfast and bedtimes. The service users are given a choice of having keys to their bedrooms and the front door of the home. The service users that have not taken up this option have the reasons recorded on their personal files. It is the home’s policy not to enter a service user’s room without knocking or calling out. Pets are allowed subject to risk assessment and agreement of the service user group. The home currently has a house cat and tropical fish. The service users’ open their own mail, or with a member of staff if needed. Breakfast is provided and a cooked breakfast is available at the weekend. Lunch is provided and service users have a packed lunch when they attend day centres. Supper is the main cooked meal of the day and consists of group and individual menus. Diabetic meals, soft, and cultural meals are also included. Menus were observed to provide a reasonably varied diet and this was balanced with informed service user choice. The last inspection report contained the following recommendation: Menus should be produced in formats that promote independence, and that are accessible to the service users. This has now occurred and this recommendation is met. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 16 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): Standards 18, 19, 20, and 21: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is well managed as staff have had approved and accredited medication administration training to promote safer medication administration. Residents’ choices and rights with regard to ageing and death are held with the highest regard and care is provided above the minimum standard at these times. EVIDENCE: Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 17 The service users’ preferences for how their support with personal care is carried out is now being recorded so that staff can carry out this support in the manner that service users prefer. Personal care needs are detailed in service user plans. Plans indicate that where possible service users are supported to be independent. The service users placed currently, do not require hoists or other aids and adaptations at this time. The level of physical support with personal care is therefore currently not high. Staff support with service users’ personal care is mainly to promote and support independence. A person of the same gender provides assistance with personal care. Personal care is provided in private, and timings of this are also flexible. Likes and dislikes are recorded. The home provides consistency and continuity through designated key workers. Access to opticians, dentists and audiologists was demonstrated. District nurses and other healthcare professionals attend when required. Evidence was seen of regular monitoring of service users’ health. The service users are registered with a local G.P and have regular check ups. A record of all appointments and check ups are kept. The service users’ health is discussed at handovers and reviews. Part of the key worker role to monitor the health needs of the service user. The manager demonstrated knowledge of the health status of individual service users. None of the current service users are able to completely self medicate. However, procedures and a lockable space in service users’ rooms are present to facilitate this where appropriate. All staff who administer medication have had approved medication training. The home has a copy of the British Medical Association guide to medication in place. Medication profiles and clear medication administration record sheets were seen in records sampled. Medication and the M.A.R sheets are kept securely in a locked cabinet fixed to the wall. The home’s policy is to find out the service users’ wishes regarding arrangements for terminal care and following death. Service users’ are able to spend their final days in their rooms if they want. Specialist medical care would be brought in if required and appropriate attention to pain relief given. This would be done in conjunction with GP, District Nurses and palliative care, unless there are medical reasons for an alternative setting. This following evidence of exceeding Standard 21 was presented: 1, During these periods, relatives can visit at any time day or night. 2, During these periods, relatives can stay over night if required. 3, If welcomed, the home maintains contact with relatives following a death of a service user. 4, Following a previous death of a service user, extra ‘over quota’ staff were brought in to provide extra support for the service users and staff. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 18 Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 19 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): Standards 22 and 23: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and acted upon. On the whole this home manages complaints well and there had been no complaints since the last inspection. The home’s policies and procedures relevant to this Standard generally facilitate protecting service users from abuse. EVIDENCE: There had been no official complaints made to the home or the Commission since the last inspection. It is noted however that service users’ issues were usually addressed at service users meetings or at the time they arose and did not usually need to develop into complaints. The complaints procedure was clear and contained all of the elements required to meet this standard including a response time of less than 28 days. The complaints procedure was converted into symbol subtitles through the use of the ‘widget’ symbols programme. The home has a copy of Croydon’s Vulnerable Adults Policy and staff have received training in this policy and associated procedures. The organisation also has its own Adult Protection procedure and has incorporated the Local Authority’s Protection of Vulnerable Adults Procedure into its procedures. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 20 The home also has a Gifts Policy, a Wills policy, a Whistle Blowing policy, an Aggression and Violence policy, and Restraints policy and guidance, which includes appropriate record keeping guidance. The Gifts Policy does preclude staff from receiving gifts and the Wills Policy does preclude staff from being involved in the making of, or benefiting from service users’ wills. Staff are required to read all the above policies and sign to confirm they have read and understood them. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 21 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): Standards, 24, and, 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The building, rooms and furniture generally meet the residents’ needs and provide a comfortable and safe environment which promotes independence. The home is generally hygienic and clean, homely and comfortable. This environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 22 The premises were bright, airy and clean, and free from offensive odours. There was suitable lighting and ventilation. Automatic fire door closing devises are present on fire doors. See also ‘brief description of service’. The grounds were well kept, and accessible to the current mobile service user group. The home has a maintenance book that records the date that an item requiring maintenance was identified and the date that it was addressed. This book shows a timely response to maintenance issues arising. The building was clean and tidy and was free of offensive odours. This has been confirmed by the service users. The home has specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, and dealing with spillages. There are Control Of Substances Hazardous to Health data sheets in their own file. Protective clothing was observed to be present. Laundry facilities have easily cleanable non-permeable floors and walls. Washing machines had appropriate programmes over 65 degrees to control risk of infection and a sluicing cycle. There is a separate sluice. The laundry room was positioned so that laundry does not need to be carried through the kitchen. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 23 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): Standards 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported by a staff group where 50 or more have the required qualifications. Achieving this raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures protects the residents through vigorous staff vetting. Staff receive induction and foundation training to ensure that they are appropriately trained. The supervision frequency meets the minimum standard. The service users therefore benefit from a supervised staff team. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 24 EVIDENCE: Over 50 of staff have the required qualifications. This meets the ratio set out under standard 32. This home has an equal opportunities recruitment policy. External volunteers are not currently used at this home. All staff have copies of the ‘General Social Care Council’ {GSCC} standards and code of conduct. All staff are subject to a 6-month probationary period which is reviewed at that time. This home has an equal opportunities recruitment policy. The staff files sampled contained Criminal Record Bureau checks, interview notes, statements of terms and conditions, identification checks, two written references and staff photographs. At the last inspection one Criminal Record Bureau check was not specific to the setting. This was obtained from previous employment settings. Criminal Record Bureau checks must be specific to the setting to be valid.. The following requirement is was therefore set: Criminal Record Bureau checks must be specific to the setting to be valid. A new CRB had been acquired by the time of this inspection and this requirement is now met. All newly recruited staff undertake induction within the first six weeks and foundation training within the first six months of starting employment and this training is to Sector Skills Council workforce training targets and specifications. Supervision records were available to confirm that supervision was occurring to the desired frequency but there were not enough records to re-confirm that previous exceeding of this standard had been maintained. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 25 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): Standards 37, 38, 39, and 42: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and the current registered manager has the required qualification. Service users benefit from the ethos of inclusion and leadership of the home. The home’s quality assurance system involves the residents, and provides feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. The home generally promotes the health and safety of the residents, so that practices and the environment do not place their health and safety at risk Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 26 EVIDENCE: The management of this home is currently in the process of changing and those changes will be fully reflected in the next report once the new manager has been registered. This report is therefore based on the original manager still being officially the current registered manager. No negative outcomes of this change process were observed at this inspection. The current registered manager has the required NVQ 4 Registered Manager’s award and is suitably experienced to manage the home. Service user inclusion, involvement and service user consultation are areas of good practice for this home, and the service users familiarity with involvement in the home, was one of the reasons that this home was selected for the service user inspection pilot recorded in the last inspection report. This is reflected by Standard 8 – ‘service user consultation and participation in the running of the home’ being exceeded and Standard 38 ‘an open and inclusive atmosphere’, being identified as an area of good practice. See also the service user inspection pilot recorded in more detail in the last report, for further supporting evidence. There is a quality assurance system, which involves service users. The quality assurance tools include the complaints system, service user meetings, provider inspection visits, user satisfaction surveys, and an annual development plan open to service users through house meetings. The outcome for service users following the implementation of the above, has been for their issues to now also be recorded in the annual development plan, and for them to have a greater involvement in the development of the home. All of the health and safety policies and procedures relevant to this standard were seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. The testing of systems required in Standard 42 were also present and inspected. These included fire fighting equipment testing, fire warning testing, Portable Appliance Testing, 5-year wiring testing and Bacterial analysis and testing of the water supply. Control Of Substances Hazardous to Health policies and data sheets were present and all these items are locked in the storage cupboard. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 27 Evidence of good practice presented: . Standard 40, Although the relevant accessible documentation standards have now been met, the home continues to build on the current achievements, and to continually explore and develop access to all relevant documentation on an ongoing basis. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 28 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 4 3 3 3 x x 3 x Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 29 no Are there any outstanding requirements from the last inspection? 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 YA14 Good Practice Recommendations The home must provide a minimum 7 day holiday to all service users, funded by the placing authority, as a part of the contracted price. Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Brigstock House DS0000025758.V353001.R01.S.doc Version 5.2 Page 31 - 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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