Inspection on 12/06/07 for Bradbury House, Brislington

This inspection was carried out on 12th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bradbury House, Brislington 30/11/05

Bradbury House, Brislington 20/07/05

Bradbury House, Brislington 02/11/04

Bradbury House, Brislington 06/06/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Bradbury House 14 Fairway Brislington Bristol BS4 5DF Lead Inspector Sarah Webb Key Unannounced Inspection 12 & 13th June 2007 09:30 th Bradbury House DS0000026526.V339744.R02.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 Bradbury House DS0000026526.V339744.R02.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. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bradbury House Address 14 Fairway Brislington Bristol BS4 5DF 0117 9716716 0117 9853092 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) Mr Neil Bradbury t/a Bradbury House Organisation Debra Vowles Care Home 15 Category(ies) of Learning disability (15), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Bradbury House and West Town Lane are registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to fifteen persons with a learning disability, as their primary need. Their ages are from 18 to 65 years. There is currently one person who is over this age. The home offers a service to both people with autistic tendencies who may exhibit challenging behaviour, and those who may have additional mental health needs. Bradbury House is a listed building which is set back from the road in a quiet residential area. Within the grounds is a detached day care facility (the workshop), which is primarily accessed by the service users from Bradbury House. West Town Lane is a four-bedded property. It is situated on the same site but is completely detached from Bradbury House. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Unannounced Inspection that took place over one and a half days. The inspector met some of the people using the service and several of the care team. The Manager was available during the inspection, and discussion was also had with both The Area Manager and Day Services Manager. The inspection process included viewing records in relation to new admissions, care and support plans, risk management, the administration of medication, the management of behaviours and interventions, and recruitment. Further information was also provided through the Annual Quality Assurance Assessment. A tour of both Bradbury House and West Town Lane was undertaken. Interaction between staff and people was also observed during a midday meal. Comment cards were received by five relatives, and with two from Health Care Professionals. Feedback was generally very positive in the care and support offered to people. Questionnaires were also sent to people that were completed with staff support due to peoples’ complex needs. Feedback from those who were able to respond to the questionnaires was positive in how they are supported by staff. As a result of this inspection two immediate requirements were made, along with two other requirements and 3 recommendations. What the service does well: Surveys from people using the service stated that they feel well supported by staff. Surveys from relatives and professionals stated that the service provided is of a good quality. The home provides comprehensive information for prospective people to make a choice whether to move to the home. The home carries out comprehensive assessments in order to ensure peoples needs are met. The home has effective recording systems to ensure peoples’ health and welfare is monitored. The home demonstrates good working relationships with other professionals through a multidisciplinary approach. The home provides people with a nutritious and varied menu whilst encouraging an awareness of healthy eating. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 6 Staff have a clear understanding of their role and responsibilities, and awareness of peoples support needs in order support them effectively. The home has clear procedures on the use of physical intervention and the management of behaviours that are challenging. Staff are provided with regular training to ensure peoples safety. What has improved since the last inspection? What they could do better: The home must ensure the administration of all medication is recorded in order that people are kept safe. (An immediate requirement was issued) Staff must adhere to the use of specialist equipment as set out in an individual’s care plan in order that their independence is promoted. (An immediate requirement was issued) The Statement of Purpose needs to be updated to reflect the changes in registration certification providing detailed information covering all areas the home offers a service to. The home must ensure an individual’s care plan is updated with current information detailing how their needs are to be met. Review mealtime arrangements for an individual in order that they may be included with others. Risk assess staff working excessive hours in order to protect the health and safety of both staff and people using the service. Ensure there is a clear record of supervision detailing staff welfare and concerns and how they are responded to. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 7 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. Bradbury House DS0000026526.V339744.R02.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 Bradbury House DS0000026526.V339744.R02.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): 1, 2, 3, 4, & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services have suitable information to make a decision on whether to move to the home and can try out services prior to making a decision. The needs of people using the service are assessed to ensure that their needs can be met. EVIDENCE: The home has met a requirement to update the Statement of Purpose with relevant changes. Due to a review by the Commission of all registration certification, the home will now need to further update this document. The Area Manager and Manager were advised that the Statement of Purpose will be considered a key document in providing information regarding the full range of needs the home offers a service for. There has been one new person admitted to the home since the last inspection; prior to this move they were receiving a service at another home within the organisation. The manager said although there were some initial concerns as to whether the home would be able to meet this persons needs, this has not become an issue and there has been noticeable progress. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 10 The home was advised by specialist services supporting this person that it would be detrimental to their health and welfare to undergo a ‘trial’ period. It was evident that the organisation has a clear admissions procedure. Those people referred to the home would generally have the opportunity to try out the service through both day visits and overnight stays. Staff carry out assessments of prospective peoples needs through visits to individuals homes to meet families. This helps provide the home with relevant information as to whether their needs can be met. Care records identified that peoples’ care has been reviewed regularly. The home provides people with a symbolised contract including the terms and conditions of occupancy. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 11 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 adequate. The majority of peoples care plans set out in detail the action needed to support people. However action needs to be taken to ensure all care plans provide details of how peoples’ needs are to be met. People benefit from risk assessments identifying how they are supported in taking risks safely within their lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four peoples care records were looked at. These included contract, assessment of need, care plan, daily records, incident records, and inventories. All four peoples’ care plans included information relating to communication, behaviour, personal safety, likes and dislikes and life skills programmes. The care plans also addressed peoples’ psychological needs, and stated how to respond and support individuals if distressed. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 12 Three peoples care plans set out in detail the action needed to be taken by staff to ensure all aspects of their health, personal and social care needs are met. A further care plan examined, and observation of how this person is supported on a 1:1 basis during a midday meal, identified that their care plan did not contain this specific action to be taken. The home has good processes in place to review peoples’ care. These include monthly reports of each person by their keyworker. Those reports seen were comprehensive and included full details of differing life skills programmes, trips and activities people had taken part in. The home is in the process of providing individual communication packages in helping people to be involved in their care. This was demonstrated by photographic information specifically designed for an individual. The manager said this has been helpful for them and is to progress in providing similar formats for other people. People are supported to take risks safely in their daily lives. There were detailed written risk assessments, which helped to demonstrate actions are taken to ensure the home is safe for both the people using the service and staff. Bradbury House DS0000026526.V339744.R02.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): 11, 12, 13, 14, 15, 16, & 17 Quality in this outcome area is adequate. The home offers opportunities for people to take part in appropriate social, leisure and educational opportunities in order to enhance their lifestyle. People are supported to take part in holidays and community based activities. Staff help to maintain their family relationships. People benefit from support and encouragement through the daily routines of the home. People benefit from meals that offer a nutritious and varied choice and encourage healthy eating options. However staff must ensure people are supported with appropriate eating aids in order to maximise their independence and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 14 Staff spoken to said people had many and varied opportunities to access both the day service on site and other activities in the community. The day service offers planned programmes and included placements at a farm run by the organisation. Staff indicated that there were occasions when activities were cancelled due to staff being unable to cover their shift or when people are supported on holidays away from the home. However further discussion identified that the home tried to ensure that people have opportunities to go out during the day for a few hours; day trips are also organised to differing areas when colleges are on holiday. Timetables identified activities people attended and these were recorded through daily diaries. People are supported in life skills programmes that include laundry, purchasing, self care and cooking. Staff complete written records on how people participated ensuring staff monitor attendance, progress and interaction taking place. The home supports people in taking part in holidays. Some of these have been on an individual basis with a high ratio of staff. This shows the home is committed to providing a ‘needs led’ service. The manager said staff have built effective relationships with families; completed surveys returned from relatives also identified that staff help people maintain contact with their families. It is evident that the home provides a varied and nutritious menu. Much of the food supply is provided by Bendalls farm with people on placement being involved in the growing of vegetables and rearing of animals. Although the cook was not available to speak with a person spoken with said ‘the food is good…. the cook is very organised.’ They also said the cook knew what people like to eat and they have choices at meal times. The people living at West Town Lane are more involved in the planning of their meals with opportunities to cook for themselves. A midday meal identified that an individual is supported on a 1:1 basis with their meals. On the day of this visit the person ate with everyone in the dining area, however normally they would have to wait till other people have finished eating. It was evident that this created anxiety for them and they could become distressed. The need for a review of this practice was discussed with the manager taking into consideration the need for them to be included. The manager said that a person is supported in relation to their specific cultural dietary needs, as stated in their care plan. However it was also identified during the meal and through examination of their care plan that this person needed the support of an eating aid. An immediate requirement was made for staff to ensure specialist equipment at Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 15 mealtimes is used as directed through an individual’s care planning so that they are supported with their independence and dignity. Bradbury House DS0000026526.V339744.R02.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): 18, 19, &20 Quality in this outcome area is adequate. People are supported to lead healthy lifestyles with their healthcare and personal needs being monitored well. The home must improve in the recording of medication administered in order to ensure peoples’ health, welfare and safety. People are treated with respect and their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of peoples’ healthcare records evidenced that individuals’ physical and mental healthcare needs are met through regular reviews of medication and support from appropriate professionals. Care files also included information that demonstrated people have access to the General Practitioner (GP), dentist, optician, chiropodist and other health related agencies. A returned comment card from GP stated that the home provides an ‘excellent’ service. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 17 Staff monitor peoples health through monthly checks. This was identified through records kept and included peoples’ weight gain/loss and any injuries or accidents sustained. The home has good relationships with specialist services provided by Bristol South Community Learning Disability Team. A returned comment card from one of these services stated the home supports people well meeting their needs. During a tour of the home, the manager knocked on peoples’ bedroom doors, waiting for a response before entering. This demonstrates that peoples’ privacy and dignity is respected. The procedures and systems in place for administration, storage and disposal of medication were checked to monitor if the systems are safe. The medication administration charts of several people were inspected. Photographs of people are maintained with each record. This should ensure medication is administered correctly to the person named on the chart. The stock of medication held in the home was examined; the balance of some medication did not correspond with stock records. This lead to evidence that an omission had occurred and staff had not recorded medication administered to an individual on one occasion. An immediate requirement was made to ensure the administration of all medication is recorded in order that people are kept safe. Medication that was no longer required was being returned to the pharmacist. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 18 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. People benefit from effective systems for complaints and protection and can be confident that they will be listened to and that they will be protected from abuse. People further benefit from the staff team being provided with training and support to ensure their welfare and safety. The home has clear strategies in place in supporting people when they may present behaviour that is challenging. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a formal complaints procedure; there are symbolised formats of the procedure that may help some people to understand how to make a complaint; this also includes appropriate contacts and timescales to respond to any complaint. There have been no recorded complaints since the last inspection. There are policies and procedures in place relating to the issue of protection of vulnerable adults from abuse. Training records indicated that staff have attended training in abuse and that this is part of ‘core’ training that is implemented annually by the organisation. Staffing files identified that all staff have been subject to Criminal Record Bureau enhanced disclosures. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 19 Care files had clear guidelines in place for supporting people who may present challenges to the service. These identified individuals’ behavioural scale indicating to what level people may become agitated; comprehensive information identified peoples trigger points and how diversionary tactics help to diffuse difficult situations. All staff are trained in Non Abusive Psychological and Physical Intervention (NAPPI) before they support people. The home sends copies of monthly incident reports to the Commission informing of how many have taken place and how they were dealt with. A recommendation is in the process of being met in that the manager has begun to look at processes in monitoring these incidents in order to improve the existing forms to help provide more detailed information. Discussion regarding using a database to record detailed incidents was also had with the Training Manager and Manager, regarding the recording of each incident of challenging behaviour that results in physical intervention; how this could be beneficial in analysing patterns of behaviour and common factors. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 20 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. People live in a comfortable and safe environment, which is also clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bradbury House is a two storey, semi detached, listed, 17th century property. It is set back from the main road and is in keeping with the local community. In the grounds of the property there is another home for four people with a learning disability, a day facility (workshop) and the office of the organisation and a training suite, which is detached from Bradbury House. Both Bradbury House and West Town Lane come under the registration of Bradbury House. The majority of the home was viewed. This included communal areas, bathrooms, and several peoples’ bedrooms were looked at. These had been decorated individually with personal belongings indicating that peoples’ bedrooms were their own space. It was evident that some people spend time in their rooms and that their privacy is respected. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 21 The Manager said the home tries to be creative in making areas as homely as possible in line with individuals’ needs; frames are made individually to take pictures and although furniture is adequate consideration has given to its suitability. The home is in the process of being decorated in line with a planned rolling maintenance programme. The home was clean and tidy; a cleaner is employed part time and was seen working in differing areas. There was an odour prevalent in one area of the home. The Manager explained that all efforts are being made to address this issue and that advice is being sort from other agencies. There is a garden to the rear of the property; whilst one area of the garden is accessible to people, a further area is restricted and can only accessed with staff support. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 22 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): 31, 32, 33, 34, 35, & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service benefit from staff having a clear understanding of their role and responsibilities, and awareness of individuals needs. Both people using the service and staff would benefit from longer working hours being risk assessed and monitored to help ensure their safety. Effective action is being taken to ensure all staff are skilled and well trained in the work they do. Although there are processes in place for staff to be supervised, both people using the service and staff would benefit from improvements to the way supervision is undertaken. EVIDENCE: The five staff spoken with explained their previous work related experience and knowledge. They identified training they had attended and demonstrated through examples how they supported people with their care needs and Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 23 differing activities. It was evident that they were fully aware of their role and responsibilities. There are 19 care staff employed, 3 senior staff and a cook. There are currently no staff vacancies. Existing staff cover those staff who are unable to work due to sickness, annual leave or training. A member of staff also specifically coordinates the workshop area. Apart from the Home manager there is also a Day Services Manager whose role includes the management of the day service, staff supervision and monitoring of the care planning. The examination of rotas and discussion with care staff identified that there are those staff who choose to work for a 24 hour period. This would involve working an afternoon shift, through to a waking night and then straight into a morning duty. Discussion was had with the Area Manager regarding staff choosing to work these excessive hours in terms of staff having to deal with difficult situations and the health and safety of both staff and people using the service. It was recommended that the home risk assess and monitor staff working these longer hours. The Area Manager responded that this has previously been raised at another service within the organisation and since this visit both a risk assessment and new working hours/guidelines have been agreed and put in place for staff. The organisation has plans in place for the implementation of staff registering for a National Vocational Qualification. Currently senior staff are completing an assessors qualification prior to care staff being registered. Recruitment processes were examined through 4 staffing files. All had completed applications, two written references and had been through the process of an interview. A recruitment checklist identifies areas that need to be followed up prior to staff starting their employment. Staffing files indicated there are comprehensive induction systems in place. This was reinforced by discussion with staff, in that the home provides staff with a two week induction period with relevant information including the routines of the home and health and safety procedures. Newly appointed staff also shadow others who have experience, before they work on their own. New staff attend statutory training such as food hygiene, first aid, and fire, during the first few months of employment. All staff complete the Learning Disability Award Framework (LDAF). Discussion was had with the organisational Training Manager who related their role and responsibilities part of which is to organise, implement and monitor training. This was identified through training needs analysis identified all areas of staff training that is either fully met, out of date or not completed. This included core annual training such as autism, epilepsy. The analysis also Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 24 indicated that staff had attended mandatory training. This is good practice evidencing that the organisation considers training as a priority and has processes in place to monitor this. The training Manager also indicated that he made visits to homes within the organisation to work specifically with staff. This is part of the quality assurance process in evaluating the training staff have received. A senior staff member said they had attended a course on Makaton which is to be cascaded down to care staff. Feedback was good in that the management team communicate well through regular staff meetings and that the team support each other. Although senior staff have attended supervision training, Although staffing files identified that generally records of supervision were fully recorded, it was noted that in one staff file there were not sufficient minutes taken and that there was no evidence that a concern bought up in supervision by a care staff had been followed up. Bradbury House DS0000026526.V339744.R02.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): 37, 39, 41 & 42 Quality in this outcome area is good. People using the service and staff benefit from a well run home with efficient systems in place. People benefit from an effective quality monitoring system in place in order to seek their views, and others involved with their care, and act on the findings. Peoples’ rights and best interests are safeguarded by appropriate record keeping. People benefit from effective procedures and protocols in place in order to ensure their health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 26 The manager, Ms Vowles, has previous managerial experience within the organisation. She has recently been registered as manager of the home through the Commission. Ms Vowles is registered to complete National Vocational Qualification level 4. The home has good recording systems in place. Written guidelines promote staff to record information appropriately. Records are kept in the office ensuring peoples’ confidential information is held securely. All the records examined were well maintained, up to date and in order. Other records have been referred to elsewhere in this report, and demonstrate well-organised management in the home. Senior staff are trained in areas of health and safety, and have responsibilities for the monitoring of this area. Examination of the fire log indicated that all staff have received annual fire training and have been involved in fire drills. Fire maintenance records indicated that fire equipment is inspected on a regular basis by both staff and contactors. Records identified that both the electrical hardwiring certificate and portable appliance testing were in date. All cleaning materials and other harmful substances are stored securely in line with the homes policies and procedures. Records are kept of bath water temperatures that are taken prior to people bathing. The home keeps a record of accidents and incidents and keeps the Commission informed through regulation 37 notifications of the same. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 27 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 2 2 3 3 3 4 3 5 3 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 3 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x 3 3 x Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 28 YES 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. Standard YA1 Regulation 4 Requirement Ensure the home’s Statement of Purpose is updated to reflect recent changes in line with the registration certificate providing full information in relation to the full range of people a service is provided to. Ensure care plans provide details of how peoples’ needs are to be met. Ensure staff adhere to the use of specialist equipment as set out in a care plan. (Immediate requirement) Ensure all medication is recorded. (Immediate requirement) Timescale for action 30/09/07 2. 3. YA6 YA17 15 12 31/07/07 14/06/07 4. YA20 13(2) 14/06/07 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. Refer to Standard YA17 YA33 Good Practice Recommendations Review the arrangements for an individual’s meal time. Risk assess staff working excessive hours. DS0000026526.V339744.R02.S.doc Version 5.2 Page 29 Bradbury House 3. 4. 5. YA36 YA6 YA23 Ensure there are clear supervision records detailing all aspects of staff’s development, welfare and concerns. Continue to review communication strategies/accessible formats in order that service users are involved in their care planning in a meaningful way Review/improve the recording of each incident of challenging behaviour/physical intervention. Bradbury House DS0000026526.V339744.R02.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Bradbury House DS0000026526.V339744.R02.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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