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Inspection on 26/06/07 for Bradbury Lodge

Also see our care home review for Bradbury Lodge for more information

This inspection was carried out on 26th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Bradbury Lodge has a staff team who continue to be committed to supporting the people who live at the home to lead full and active lives as far as they are able. People who spoke with the inspector said that they liked the staff. Staff felt they worked well as a team. The majority of people who live at Bradbury lodge have regular opportunities to access community resources and support profiles are detailed enabling staff to adopt a consistent approach. The home has successfully implemented a process of reviewing behaviours and incidents and using information gathered to make recommendations for better approaches to supporting people. This process is considered by the inspector to be a strength of the organisation and along with other data gathering methods forms an effective assessment process that has led to design briefs being drawn up for people to `move on` from the home.

What has improved since the last inspection?

Since the time of the last inspection Bradbury Lodge has become more `homely` and the staff team have continued to build on the strengths of the interim management arrangements. The AQAA states that improvements have been made to the home`s Admission and Discharge policy that `has enabled clarity of the service provision as well as the roles of the management and staff`. The imminent admission of the sixth resident will test the process. Arrangements for the administration and storage of medication have also improved since the time of the last inspection of the home although a few minor additions are to be made. People who live at Bradbury Lodge are being supported to enjoy healthier meals and the menu is being reviewed accordingly.

What the care home could do better:

Staffing levels at the home continue to be an area where improvements could be made to ensure better opportunities for people and to enable incidents to be managed safely on all occasions. Service users have commented that activities and mealtimes are affected when there are insufficient staff on duty. Staff feel that staffing levels could be better, some have expressed anxiety to senior managers about the issue. Concern was raised in relation to one service user in particular whose opportunities are limited. Another area of concern, identified at the time of the inspection, is in the recording and investigating of complaints. On at least one occasion action taken was clearly inappropriate and may have made people vulnerable as a result. The AQAA suggests that the Complaints book is up to date with outcomes recorded. Although this is factually correct it demonstrates that management have not identified poor and inappropriate practice.

CARE HOME ADULTS 18-65 Bradbury Lodge Claypit Road Whitchurch Shropshire SY13 1NT Lead Inspector Sue Woods Key Unannounced Inspection 26th June 2007 09:45 Bradbury Lodge DS0000063738.V338589.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 Bradbury Lodge DS0000063738.V338589.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. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bradbury Lodge Address Claypit Road Whitchurch Shropshire SY13 1NT 01948 666916 01948 667011 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) Perthyn Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home accommodates service users only between the ages of 18 and 65 years. Mr Ogundere must undertake NVQ level 4 in care within 12 months. Perthyn must supply details, within their statement of purpose, of support networks available to the manager and staff including relevant qualifications, to demonstrate the manager will be appropriately trained and supported. The home may only accommodate service users for an assessment period of a maximum of two years, with a plan to move on developed after the first year. When occupancy at the home reaches four service users Perthyn must consult with CSCI to formally review existing arrangements (including assessments and support plans) and identify future needs of proposed service users by way of staffing levels and individual needs. 11th December 2006 4. 5. Date of last inspection Brief Description of the Service: Bradbury Lodge is a ‘short term’ assessment unit for adults with ‘or have a history of’ (taken from the statement of purpose) challenging behaviours. It has been identified that the people moving in are people whose needs previously could not be met in the County and thus alternative placements further afield had been made. The home is managed by Perthyn and registered to support a maximum of six people with learning disabilities. The manager of the home is Mr Richard Halliwell. The Responsible Individual is Ms Bethan Evans. Information is shared with service users in the service user guide and within regular in-house meetings. A Quality of Life Questionnaire is carried out with all service users and outcomes are recorded in support plans and are used to identify future goals. Fees are paid by the local authority on a block contract basis and individually range from £110,319 to £114,580 annually. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Bradbury Lodge took place on 26th June 2007 between 09 45 am until 04.00 pm. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the fieldwork activity the inspector spoke with service users and staff and reviewed records including support plans and other records as detailed within the report. The deputy manager gave out, on behalf of CSCI, surveys for staff to complete and return to the inspector. At the time of the completion of this report no surveys had been received. The new manager of Bradbury Lodge was on duty at the time of the inspection. What the service does well: Bradbury Lodge has a staff team who continue to be committed to supporting the people who live at the home to lead full and active lives as far as they are able. People who spoke with the inspector said that they liked the staff. Staff felt they worked well as a team. The majority of people who live at Bradbury lodge have regular opportunities to access community resources and support profiles are detailed enabling staff to adopt a consistent approach. The home has successfully implemented a process of reviewing behaviours and incidents and using information gathered to make recommendations for better approaches to supporting people. This process is considered by the inspector to be a strength of the organisation and along with other data gathering methods forms an effective assessment process that has led to design briefs being drawn up for people to ‘move on’ from the home. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 8 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. Appropriate procedures are in place that would enable the successful admission of a new service user to the home. EVIDENCE: Five people currently live at Bradbury Lodge. A sixth person is due to move in soon and the organisation is currently spending time getting to know the individual and has produced a comprehensive assessment of needs. The manager stated that he is currently in the process of sending him a Service User Guide and a copy of the last CSCI inspection report. Pre admission visits have been planned for the near future. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 9 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, 9 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Person centred care and support plans enable staff to offer people choice and assist with decision making as well as delivering care in a way that they prefer. However these plans are currently being affected by the behaviours and actions of others living at the home. Risk assessments ensure that support is given in a safe manner although if they are not reviewed the home cannot demonstrate that they are still appropriate. EVIDENCE: Two care files were chosen at random and reviewed by the inspector. There was evidence that plans have been reviewed by the team including the behavioural support specialist who is largely based at the home. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 10 Assessments were detailed and there was evidence that reviews have taken place of incidents and behaviours. Recommendations for improved practice have been made as a result. People who live at Bradbury Lodge told the inspector that they are involved in decisions made about their lives and the activities they take part in. Staff supported this and gave examples of how people are consulted. House meetings used to form an integral part of this process however have become less frequent. Reasons were given for this that are to be addressed by the manager. People who live at Bradbury Lodge are fully involved in their three monthly and quarterly reviews. Staff said that service users help with cooking and cleaning tasks although independence has been limited by the decision not to use the small kitchen to make drinks and snacks when the main kitchen is locked. Risk assessments were seen to be in place to support activities of daily living however review dates were overdue. The manager stated that he would make the review of these assessments a priority. It was reported that the behaviours of one person who lives at Bradbury Lodge affects the ability of others to make decisions and choices. The manager stated that one person ‘rules the roost’ and staff, in discussions, supported this. Issues in relation to the confidentiality of information were identified in the home’s complaints book and will be discussed later in this report. Design briefs have been developed to support at least three people to move on from the home. They are waiting for the local authority to identify suitable placements. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 11 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, 15, 16 and 17 Quality in this outcome area has improved and is good overall This judgement has been made using available evidence including a visit to this service. The majority of the people who live at Bradbury Lodge lead full and active lives enabling them to have new experiences and develop new skills. Service users are working towards having a more a balanced and varied diet. EVIDENCE: People who live at Bradbury Lodge access the community on a regular basis however staff commented that the quality of activities could be improved upon. One individual has made a formal complaint about not being able to take part in planned activities due to inadequate staffing levels. Staff agreed that this is sometimes the case. On the day of the inspection one man was going for a hair cut and then to the cinema. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 12 One person living at Bradbury Lodge showed the inspector his activity planner and talked through his plans. He was happy with the activities that he had planned. The planner of a second individual was seen on his care file. The planner supported staff discussions identifying that new activities are planned on a regular basis. In discussions the majority of staff felt that activities had improved ‘a lot’ although all reflected on barriers to activities taking place, mainly staffing levels. Since the time of the last inspection the home has started working with a dietician at a local college to review and rewrite the menus. The menu seen by the inspector reflected a variety of foods available and staff stated that they try to accommodate everyone’s preferences. Everyone acknowledged that there was further work to do in this area but feedback was positive on progress so far. Some staff felt that further work is needed in relation to consistency and review of purchasing foods by individuals. For example despite a more healthy mealtime menu one person still eats a lot of sweets and drinks fizzy pop. Family contact is supported and encouraged. The behavioural specialist who works for Perthyn is currently working towards a qualification in ‘Sex and Relationships for people with learning disability’. This supports and develops work she has done with named individuals. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 13 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 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The personal and health care needs of the people who live at Bradbury Lodge are generally well met enabling them to have a good quality of life. People are safeguarded by the home’s system for handling, storing and administering medication although improved written communication in some circumstances will offer better protection. EVIDENCE: Service user files contain details of health care appointments and document outcomes. There is evidence that the health care needs of service users are taken seriously and referrals and appointments are made as appropriate. Information in relation to identified medical conditions were seen on files. Health action plans have been implemented and the one seen by the inspector was very person centred. Support profiles contain very detailed information relating to individual support needs and preferences. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 14 Medication arrangements within the home have again improved and staff said that new procedures were much better. Records seen by the inspector were well maintained and up to date. Arrangements for the recording and storage of controlled drugs were also good. Daily records were seen to reflect when medication had been administered ‘as and when required’ although the reason for this had not been recorded. Although the staff member who showed the inspector the medication arrangements was aware of how and when to administer an identified medication there was no written guidance to support it. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 15 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 poor This judgement has been made using available evidence including a visit to this service. People who live at Bradbury Lodge are vulnerable if the home does not appropriately investigate and refer complaints. People are safeguarded by robust procedures for supporting money management. EVIDENCE: People who live at Bradbury Lodge told the inspector that they felt their views were listened to and that they knew who to speak to if they had a concern or complaint. The home’s complaint book supports that people feel comfortable to record their concerns in a formal way however the process is in need of urgent review. The complaints book listed a number of complaints made by people living at the home since January 2007. The book is laid out to identify the nature of the complaint and the action taken. The book suggests that the home does not always take appropriate action following receipt of a complaint. On one occasion an incident that would warrant a referral to the safeguarding Adults team had been poorly investigated. The manager said that he would take immediate action to address this issue as he was previously unaware of it. A review of complaints recorded supports issues in relation to staffing levels affecting activities and on one occasion people couldn’t have their meal until an incident had been dealt with. There is no evidence that any complaint had Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 16 been satisfactorily resolved despite the homes AQAA stating that 86 had been resolved within 28 days. The procedure for supporting people to manage their money was seen and staff said that they felt it was effective. Records seen demonstrated that regular checks take place. One person who lives at Bradbury Lodge invited the inspector to watch him organising his money with the support of a staff member. Staff were aware of his personal preferences and the individual enjoyed the responsibility of managing his own money. Service users were able to access the complaints book and write in complaints. This means that confidential information recorded by others is accessible to everyone. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 17 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. People who live at Bradbury Lodge are provided with a clean and wellmaintained place to live. EVIDENCE: At the time of the last inspection of Bradbury Lodge suggestions were made by the people who live there for improvements to the environment. These have been actioned. There are now pictures in the lounges and overall the home feels more ‘homely’. All areas were found to be clean and tidy at the time of the inspection. The manager reported that COSHH products were kept to a minimum and this was seen to be the case. The AQAA states that written assessments support COSHH products although the manager couldn’t access the file to demonstrate this on the day of the inspection. The manager also reported that maintenance tasks are carried out promptly although damage to an outside door had reportedly occurred a while ago and it was still damaged on the day of the inspection. The manager stated that he would address this issue. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 18 The small kitchen that was developed for use by people who live at the home to make drinks and snacks when the main kitchen is locked no longer offers this service. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 19 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): Standard 32, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who live at Bradbury Lodge benefit from being supported by a competent and committed staff. Service users will benefit from additional staffing resources being available to support activities and safety may be compromised if adequate staffing levels are not implemented. EVIDENCE: Staff on duty at the time of the inspection were motivated and enthusiastic. Interactions between staff and the people who live at the home were seen to be very positive. Staffing levels continue to be a cause for concern. The manager stated that there should be a minimum of five staff on duty at all times. On the day of the inspection there were four and the previous Sunday there was also four. Staff reflected this finding in conversations stating that sometimes there is ‘not enough’ staff and that weekends are ‘difficult’. The manager stated that he was reviewing the rota as his first priority. People who live at the home have Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 20 complained about staffing levels and stated that on at least one occasion the mealtime was delayed due to staff responding to an incident. The manager was aware that staffing levels impact on activities for service users. Examples from staff were given which confirm this problem It was also identified that staffing levels need to be reviewed at certain times of the day in order to safely support people. Staff on duty said that they have received some training since December 2006 and it was positive that the staff member ‘shadowing’ on the day of the inspection had received his behaviour management training to enable him to respond appropriately to incidents of challenging behaviour. The manager was unable to access staff files at the time of the inspection as he didn’t have the key. He stated however that he could readily access emergency contact information. He could also confirm that no one works at the home until CRBs have been received and this was confirmed upon review of the last Regulation 26 visit report and the AQAA. Staff felt well supported to do their jobs and senior staff said that formal supervisions take place. Team meetings do not happen regularly although the manager said that he was also going to schedule one for the near future to formalise new management arrangements. One staff member currently on induction is happy with the information he has received and is currently reading policies and procedures. On the day of the inspection he was shadowing staff and a service user felt that he was ‘doing well’. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 21 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): Standard 37, 39 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who live at Bradbury lodge have been supported by an effective interim management team although some areas of management responsibility have not been addressed and as a result people have been left vulnerable. EVIDENCE: Since the time of the last inspection there have been significant changes in the management arrangements of the home. The interim management team based in Cardiff withdrew and the deputy manager assumed an ‘acting up’ position. The registered manager of the home formally resigned recently and the previous Regional Manager has been recruited into the manager’s post. He is aware of his responsibilities to apply for registration with CSCI but only took up post two days before the inspection. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 22 This inspection has identified improvements that have been made to the service since the time of the last inspection demonstrating the commitment of all involved and reflecting positively on interim management arrangements however areas such as complaints have required management input that has not happened and as a result made people vulnerable. The AQAA for example suggests that ‘the Complaints book is up to date with outcomes recorded’. Although this is factually correct it demonstrated that management have not identified poor and inappropriate practice. Discussions with the responsible individual following the inspection confirmed that the new manager had been overseeing the management of the home since January 2007. Staff feel positive about new management arrangements although all felt it was too soon to comment on them. The manager is currently working on the homes Fire Risk Assessment in line with new legislation and guidelines. He also plans to send staff on fire officer training. Water was safely regulated in the bath chosen at random for testing and the manager has identified some health and safety issues and begun to address them. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 23 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 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 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 24 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 Standard YA20 Regulation 13 (2) Requirement Timescale for action 01/08/07 2 YA22 22 (3) 3 YA33 18 (1) (a) 4 YA23 13 (6) The home must ensure that written guidelines support the administration of medication given as and when required or mistakes may be made. The reasons for the administration of such medication should also be recorded so that people who live at the home do not receive medication inappropriately. Complaints must be investigated 01/08/07 appropriately and outcomes recorded to demonstrate that the home has taken the complaint seriously and listened to the complainant. The home must ensure there are 17/07/07 sufficient staff on duty at all times to ensure the safety of the people who live there and to enable them to live full and active lives. The home must refer allegations 17/07/07 of abuse to the appropriate body for investigation. This is to ensure that they are investigated openly and that appropriate action is taken to safeguard the victim. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 25 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 YA10 YA13 Good Practice Recommendations Information should be shared on a need to know basis only to respect the confidentiality of individuals The home should ensure that all people who live at Bradbury Lodge have the same opportunities to access community activities. Bradbury Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Lodge DS0000063738.V338589.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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