Inspection on 31/08/05 for Bradbury House

This inspection was carried out on 31st August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bradbury House 09/08/07

Bradbury House 27/10/06

Bradbury House 21/02/06

Bradbury House 18/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bradbury House Windsor End Beaconsfield Bucks HP9 2JW Lead Inspector Caroline Roberts Unannounced 31 August 2005 4.45pm st 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 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. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bradbury House Address Windsor End, Beaconsfield, Bucks, HP9 2JW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01494 671780 01494 672533 The Abbeyfield Society Limited Mrs Wendy Stallwood Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: Bradbury House is a purpose built residential home registered to provide care for up to forty-one elderly people. It is situated in a pleasant residential area of the old town of Beaconsfield, close to local shops, market place and the Church. The home provides comfortable accommodation for service users in single bedrooms and spacious social areas. There are accessible attractive and well-maintained gardens. Car parking is available to the front of the home. The local Abbeyfield Beaconsfield Society is responsible for the Management of the home and provide a House Committee. Service users are registered with local GP Practices and have access to local NHS Services through GP referral. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the un-announced inspection carried out at Bradbury House on the 31st August 2005, commencing at 5.20pm. The lead inspector was Mrs Caroline Roberts. The inspection consisted of meeting with Residents and staff, viewing records and documents pertaining to the provision of care and the running of the home. The inspector toured the building, gaining permission from a number of residents to enter their bedrooms and viewing a further number from the doorway. The inspector met and discussed the inspection findings with the deputy manager, and manager before leaving. This inspection has resulted in two requirements being served. The inspector found staff polite, helpful and welcoming, and would like to thank them for their co-operation and assistance throughout the course of the inspection. The inspector would especially like to thank the residents for their time and for allowing the inspectors into their home. What the service does well: What has improved since the last inspection? Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 6 Decoration of the corridors, and new carpets in this area. Ongoing decoration of the home as part of a rolling programme. 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. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 Current and prospective residents have adequate information provided in the homes Statement of Purpose and Service User Guide, to enable informed choice about where they live. Pre-admission assessments do take place in this home however; a judgement cannot be made as to the level of detail contained within these documents due to them not being available during the inspection. EVIDENCE: A copy of the Service user Guide is given to all of the residents, and any prospective residents. The senior member of staff on duty at the time of the inspection said that the manager updates this document periodically. The pre-admission assessment files for three residents were viewed: One contained a resident detail form and no other information. The others viewed did not contain a detailed pre-admission assessment, the senior on duty called the manager at home to ask if pre-admission assessments would be located outside of the file. The home were unable to produce these documents for inspection. The manager informed the inspector via telephone Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 9 the following day that the assessments were upstairs awaiting filing, but had been conducted. Quite clearly the manager needs to ensure that these documents are maintained alongside the care plan. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 The home has a care planning system in place, however, those care plans viewed were inconsistent in the level of information recorded; therefore residents needs are not clear or up to date and do not enable staff to provide the most appropriate care. EVIDENCE: Three care plans were examined during this inspection, all of the care plans viewed reflected the needs of the resident, evidence of resident and family involvement with the care plans was seen. Moving and Handling assessments were completed with evidence of review. It was noted that one resident with a specific health care need was not being monitored appropriately, for example diabetes care blood sugar readings in between 3 and 25 with no evidence of any advice/action being taken. Another resident who was being cared for in bed did not have an appropriate tissue viability risk assessment fully completed detailing the action required by staff. Daily reports are not being completed fully, with no information entered for 3 days with one resident, the care plan did not indicate if this resident had gone into hospital during this time. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Not assessed during this inspection. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a complaints procedure, which is accessible to residents and families however; it is difficult to judge the effectiveness of this if it is not used fully with all complaints logged with actions taken to address complaints. EVIDENCE: The home has a complaints policy, which meets requirements, and which is understood by staff. The complaints policy is available for residents and relatives. One resident discussed a complaint she had made to the management regarding her concerns around the pond in the garden, this complaint had originally been given verbally to the manager, and then a written complaint had been sent. No record of this could be found in the complaints log. Another complaint from a relative of a resident was detailed within the complaints log regarding the quality of the food. The manager had responded the following day with a letter however, no record of any investigation or outcome was available. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,26 Residents live in a safe well-maintained environment, which includes specialist equipment to maximise independence. The home is clean pleasant and hygienic throughout. EVIDENCE: The location of the home and its stated size and layout are well suited to the homes stated purpose and resident needs. It is a fairly modern, accessible home comprising of car parking facilities, large clean en-suite rooms with adapted bathrooms available. Residents have access to all communal areas and to their bedrooms at all times of the day and night. The home was clean and tidy (with the exception of the main kitchen see standard 38) the standard of décor is adequate. Since the last inspection the corridors have been re-decorated and new carpets fitted. All of the bedrooms are individually furnished to the likes of the occupant, residents are able to personalise their bedrooms. The home has a passenger lift, assisted bathing facilities and hoisting equipment. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 14 The main lounge downstairs has French doors, which open out, onto the garden, which has a central paved courtyard, with raised flowerbeds and seating area. This area is accessible by all the residents. The bathrooms and toilets are equipped with hoists and adaptations. Evidence was seen that these are regularly serviced. Laundry facilities are suitable for the size of the home. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Residents are supported by sufficient numbers of suitably trained and skilled staff ensuring the needs of residents are met at all times. EVIDENCE: At the time of the inspection 6 care staff were on duty, it was confirmed to the inspector that this was adequate to meet the needs of the current resident group. The rotas were examined. This highlighted that they were not accurate, it detailed that the manager was working a late shift when she was not in the building, a high use of tippex was also noted on this document. The manager is reminded that correction fluid should not be used, and that the rota needs to reflect the actual staffing. Recruitment records were not available during this inspection due to the manager not being present; therefore this will be assessed during the next Inspection. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The Health, safety and welfare of residents, staff and visitors is protected by the homes policies however, the manager must ensure that areas within the home maintained by contractors are still covered by the homes policies and procedures. EVIDENCE: The home has service agreements in place for: Boilers Lifts Hoists Electrical equipment Contractual arrangements are also in place for clinical waste. Fire safety records are well maintained. The home has recently commenced a new contract with a catering company who will be responsible for all of the catering needs of the home; this includes Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 17 maintaining the cleanliness of the kitchen. It was therefore disappointing to note the state of the kitchen: Open pots of assorted spices on the side Open packets of dry food in the storeroom Uncovered, undated food in the fridge (including meet) Fridges dirty Food debris all over the floor Carrots and potatoes prepared for the following day by 6pm in pans not covered. Ovens covered in dried food The trainee chef on duty was unable to produce the hazard analysis, and appeared not to understand what these were for. The full time chef then came into the home, he was also not able to produce the hazard analysis. It transpired from conversations with both of the chefs that they do not have CRB disclosures. It is the managers responsibility to ensure that residents are protected by the homes recruitment policies this includes contract staff. Having been concerned about the Kitchen, it was pleasing to note that the managing director of the kitchen contracting company visited the home the following day to arrange for an audit to be undertaken to improve practice immediately. The inspector was copied into the action plan following this visit; this will be monitored at the next inspection. Chairs stored in corridors should be removed as this presents as a fire hazard. Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x x x x x x x 2 Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 19 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. 1. 2. Standard 38 16 Regulation 16.2(j) 17.2 Schedule 4(11) Requirement The manager is required to ensure satisfactory standards of hygiene in the kitchen. The manager is required to ensure that all complaints are documented in the complaints log with details maintained of any investigation/outcome. Timescale for action 1.12.2005 1.12.2005 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 Good Practice Recommendations Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 20 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park Smeaton Close, Aylesbury Buckinghamshire HP19 8JR National Enquiry Line: 0845 015 0120 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 Bradbury House 20053108 Bradbury House X00015 UI Stage 5 S19182 V247247 H53.dot.doc Version 1.40 Page 21 - 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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