Inspection on 03/05/06 for Bradbury Lodge

This inspection was carried out on 3rd May 2006.

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 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bradbury Lodge 26/06/07

Bradbury Lodge 11/12/06

Bradbury Lodge 06/01/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Bradbury Lodge Claypit Road Whitchurch Shropshire SY13 1NT Lead Inspector Sue Woods Key Unannounced Inspection 3rd May 2006 9:30 Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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.V292546.R01.S.doc Version 5.1 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.V292546.R01.S.doc Version 5.1 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 Mr Oluwajimi Oluwayemisi Ogundere Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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. 6th January 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 a field had been made. The home is managed by Perthyn and registered to support a maximum of six people with learning disabilities under the age of sixty-five years. The registered manager of the home is Mr Oluwayemisi Ogundere and the Responsible Individual is Mr Richard Halliwell. Conditions of registration apply and are detailed above. The service fees are paid by the local authority on a block contract basis A breakdown of these fees and costs to service users individually are not clear. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Bradbury Lodge took place from 9.30 am to 4.30 pm on 3rd May 2006. The inspection reviewed all 22 key standards and information to produce this report was gathered from the finding on the day and also by review of information received by CSCI prior to the inspection date and during a meeting held on 9th May 2006 with senior managers. 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. On 3rd May the inspector spoke with service users, staff and the manager of the home and reviewed key records, including care plans. What the service does well: What has improved since the last inspection? Since the time of the last inspection staffing levels have improved within the home although it is acknowledged that short-term solutions will not provide consistency for service users or other members of the staff team. The rota now reflects five staff on each shift, sometimes more, and these levels are maintained at weekends and on bank holidays. Staff acknowledge staffing levels are better although everyone who spoke to the inspector identified Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 6 higher ratios would be beneficial to enable service users to maximise independence and access community resources on a more regular basis. Medication arrangements have on the whole have improved in relation to storage and administration however errors continue to be made in relation to the record keeping. 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 Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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.V292546.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of information available does not enable the home to demonstrate that it can meet the needs of service users moving in. Service users are disempowered if they do not know what they are entitled to as part of their care package with Perthyn. EVIDENCE: Five service users are currently living at Bradbury lodge. It was requested by CSCI that prior to the admission of the fifth person that information was shared to demonstrate that the home had sufficient staffing and accurate and up to date assessments of needs and risks to ensure the safe admission of the individual. This information was not supplied and despite concerns raised by the manager of the home and CSCI the admission took place. Upon review of his file on the day of the inspection it was seen that a care plan had been developed on 22.2.06. He moved in on 26.2.06. Contracts between Perthyn and the placing authority are not available at the home and the only statement of terms and conditions between Perthyn and service users is the service user guide that contains basic costing information. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 9 The pre admission assessment for the sixth service user was seen. It was dated December 2004 and makes comments suggesting that the service user should not live with people who have challenging behaviours. No further documentation is available to suggest that compatibility issues with others living in the home have been addressed. During a meeting held at the CSCI office on 9th May 2006 it was stated that there is more documentation now available however it had been done by the clinical team and without input from the home manager. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are enabled to access activities of their choice and are aware of their present and future plans. Service users feel consulted and involved in planning and decision-making processes. Risk assessments are on occasion restricting activities and opportunities for service users and on occasion reflect a resource led service. The lack of updated specialist support plans is placing service users and staff at risk of harm. EVIDENCE: There were four service users at home on the day of the inspection. One service user had gone to college and when he returned was happy to report that his move to a more local college was imminent. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 11 The activity plan for the latest service user to move in to the home suggests that he has planned outings at least three times a week, including bird watching, trips to the library and a visit to the chapel. The ‘about me’ information seen on one file reviewed details likes and dislikes and support needs. Information seen on this document was reflected in the discussion with the service user and his most current activity plan. Care plans were available on both files reviewed although it was noted that specialist information and input was not readily available. For example one service user who was seen to be displaying challenging behaviours that warranted a restraint at the time of the inspection did not have an individualised plan on his file. The manger reported that generic training had been given but nothing individualised. (This was disputed by the clinical manager for Perthyn during the meeting on 9th May 2006). It was also of concern that the service users challenging behaviours had escalated and risk assessments and care plans had not been reviewed and updated to support his changing needs. Staff told the inspector that they would welcome some protocol or guidance as to when they should actually initiate a restraint. Key workers were identified on the service user guide seen by the inspector. Service users knew who their key workers were and staff were aware of the responsibilities of that role. One service user told the inspector how he was supported to manage his money and service users are given opportunities to go into the community to make their own purchases wherever agreed. Where staff access service users money records are kept with corresponding petty cash sheets and receipts. (It is recommended that when service users keep their own change from purchases that this is recorded to allow an audit trail and protect staff). Despite requirements made at the time of the last inspection of the home risk assessments still do not fully support admissions although the manager and staff state that individual risk assessments are carried out for activities. (These were not reviewed by the inspector on this occasion). On one occasion a risk assessment has resulted in restrictions being placed upon the individual and others living in the home. For example the decision to lock the kitchen door after one service user received a burn will restrict further independent living plans for others and will not support the service user injured to safely use equipment in the future. On one service user’s file staffing levels are identified for safe support while at home and in the community however they are not reflected in risk assessments or in actual daily practice. The staffing risk assessment sent to CSCI from the responsible individual was seen to be service led and not person centred. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain a healthy diet and have some opportunities for an active personal and social life. Service users should be aware of restrictions placed upon them in order to decide if the home will meet their needs and aspirations. EVIDENCE: One service user stated that meals for the week are agreed at the house meeting held every Friday and that healthy options are now being tried. On the day of the inspection staff prepared, with input from one service user a baked potato meal with a variety of fillings. Religious observations were seen detailed and actioned on care plans reviewed. One service user is supported to maintain contact with his local church and his vicar is planning to visit the home in the near future. Daily Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 13 activity programmes support service users to access local community resources and in conversations with service users and staff it was confirmed that local resources are utilised and enjoyed wherever possible. Family contact is maintained and supported with staff input as appropriate. Service users told the inspector that they felt that they were listened to and supported with all activities of daily living. As previously stated it is important that restrictions placed on one service user do not impact on the rights of others living at the home. Any agreed restrictions should be detailed in the home’s statement of purpose. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The personal and health care support needs of service users are met effectively however service users remain vulnerable as a result of medication recording errors and the possible inconsistent approach to authorising medications taken as and when required. EVIDENCE: Personal and health care support details are recorded on individual files and during conversations with the inspector staff were knowledgeable about individual needs and requirements. Medication administration and storage arrangements have improved since the time of the last inspection of the home. Dosset boxes have been introduced for service users requiring medication and the administration of medication at the time of the inspection visit was observed to be discreet and well organised. Despite these improvements errors still occur in recording practices and the manager is in the process of carrying out an investigation into a recent recording error. A formal warning given following a previous error was not documented on the staff members file and although the manager stated that he had carried out a Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 15 competency review the paperwork to support this could not be found. PRN medication can only be administered after consultation with the on call manager however there is no written protocol to guide its administration. In order to ensure consistency such guidance would be useful for staff and other managers. The manager committed to put arrangements in writing. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An awareness of the homes complaints procedure and local adult protection procedures enables service users to feel confident that any issues will be dealt with appropriately. EVIDENCE: There have been no complaints received by CSCI or Perthyn relating to the service provided at the home therefore the inspector took time to discuss the complaints procedure with service users and staff. Service users named their key worker as the person they would talk to if they had a complaint. One service users would speak to the manger directly. Staff stated that they ‘talk service users through’ the complaints procedure when they are admitted and when they review the service user guide. It was a requirement of an assessment plan that all staff receive training in the local adult protection procedures. The manager was able to demonstrate through a record of training received that the majority of staff have received this training. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recent repairs have improved the standard of accommodation however the restriction imposed by the locking of the kitchen does not reflect the ethos of the home. The safety of service users and staff is being compromised by the inappropriate construction for ‘smokers’ in the garden. EVIDENCE: It was encouraging to note that the works identified as outstanding at the time of the last inspection of the home have now been attended to. Personal protective equipment was found readily available in all appropriate areas. A newly erected ‘smoking area’ in the garden was not suitable for the purpose. It was made of wood and due to its design has already been damaged. The Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 18 outside laundry door is still awaiting repair although it has been reported. It was noted that arrangements are not yet in place for the responsibility of repairs and maintenance to be handed over to Perthyn. Emergency repairs in the interim can be authorised by the home manager. Final arrangements will only be made once the sixth person has been admitted to the home. The newly implemented policy of locking the kitchen door is placing restrictions on service users. See requirement made in standard 9. One service user told the inspector that he enjoys a game of ‘solitaire’ on the computer in the quiet room. All areas of the home were clean on the day of the inspection. Suitable arrangements for the storage of substances hazards to health were seen to be in place. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are currently benefiting from adequate staffing levels. Mandatory training opportunities for staff are good and service users will benefit from staff having opportunities to attend specialist training. Service users may be vulnerable if the organisation cannot demonstrate that all appropriate checks have been made prior to their appointment. Staff may be vulnerable if the home does not have their basic information available at the home. Service users are supported by an enthusiastic and committed staff team. EVIDENCE: The manager has records supporting that the majority of the staff team have carried out all mandatory training. However some service user assessments stated that additional training is required. For example one assessment states staff require training in mental health and this has not taken place formally Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 20 although some input has been given to staff during pre admission briefings. Staff reported that training in ‘Autism’ is planned for a couple of weeks time. Staff also reported that training has, on occasions, been cancelled and rescheduled due to staffing issues. Staff have not done the LDAF induction or foundation standards and as yet have not started NVQs and this will be reviewed in more detail at the time of the next inspection of the home given that this is a fairly new service. The inspector spoke with four staff on duty at the time of the inspection and received written feedback from another. Staff demonstrated a commitment to offering a good quality service to service users although acknowledged that staffing issues have proved problematic. A review of the rota and discussions with staff identified that the home is currently able to meet the need of service users living at the home although the manager would like to see service users going out every day and not just three or four times a week. Staffing ratios are difficult to assess as risk assessments, where available, suggest higher staffing ratios than care plans. On one occasion a review has identified that a reduction can take place in numbers of staff required to support access to community resources and this has not happened. It was suggested by staff that they could work more flexibly to accommodate activities but the rota doesn’t currently allow for this. Staff shortages were resolved in the short term by seconding staff from other services within the organisation. Staff seconded to Bradbury Lodge did not feel that there was a detailed support package for the transition and the manager supports this observation, as he wasn’t involved in the moves. Staff files demonstrate a robust recruitment and selection process however there are no CRB disclosures available for review only letters stating that they have been requested. The manager holds no information on the staff seconded to the service with the exception of their phone numbers. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Communication issues within the organisation are seriously impacting on the quality of service provided and leading to failings to undertake responsibilities in relation to the homes registration. EVIDENCE: From review of records and after lengthy discussions with the manager on the day of the inspection and from meetings held with him prior to this date it is apparent that there are issues of communication within the organisation that need to be resolved before the service can be effectively managed. In an attempt to resolve some of these issues the inspector met with the manager the responsible individual and the managing director of the organisation on Tuesday 9th May 2006. The organisation’s grievance procedure has been evoked for one individual and the investigation is ongoing. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 22 Residents meetings take place on a Friday morning. The latest service user admitted to the home felt that this opportunity to meet with other service users was useful. Other service users felt that they were in control of their weekly activities. Staff reported that one service user’s planner is only completed when everyone else’s has been done and this suggests that the restraints of group living are impacting on his activities. Health and safety issues in relation to fire safety were reviewed on this occasion. Records suggest that checks take place regularly and service users responses are noted. Other issues raised throughout this report demonstrate that the home does not meet the national minimum standards in relation to health and safety. A meeting between the local authority and Perthyn is required to agree a programme of repairs and maintenance however the manager is in the interim authorised to approve emergency repairs. Arrangements have now been agreed for PAT testing of items. Regulation 26 visits are reportedly now taking place however the responsible individual is not carrying them out. Reports are not being sent to CSCI following the visits and this is an outstanding requirement. Likewise liaison between CSCI and the organisation has not been effective. Information required by CSCI prior to the admission of the fifth resident was not provided and the admission went ahead; a letter of concern written to the responsible individual and copied to a director was never acknowledged. It was identified at the time of the inspection that the director had actually left the organisation and the RI had been asked to respond. This never happened. At the meeting held on the 9th May 2006 it was agreed that the manager should assume responsibility for sending CSCI reports of notifiable incidents to CSCI as this information is not currently being sent. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 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 1 3 2 4 x 5 2 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 1 x 3 x x 2 1 Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 24 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 YA2 Regulation 14 (1) Requirement Pre admissions assessments must be current or reflect an indepth review prior to admission This requirement is outstanding from the time of the last inspection of the home Assessments must reflect that the home can meet an individuals needs and that the placement is appropriate. The home is required to provide all service users with a written statement between the home and each individual setting out the terms and conditions of residence. Risk assessments must support changes to existing assessments and implications for other service users must be acknowledged and considered. Any activities that potentially restrict service user’s independence and choice must be explained and detailed in the homes Statement Of Purpose This requirement is outstanding from the time of the last inspection of the home DS0000063738.V292546.R01.S.doc Timescale for action 12/06/06 2 YA2 14 (1) 12/06/06 3 YA5 5 (b) 12/06/06 4. YA9 13 (4)(b) 29/05/06 5. YA16 4 (1) (c) 29/05/06 Bradbury Lodge Version 5.1 Page 25 6 YA20 13 (2) A review of medication recording arrangements must be carried out and outcomes implemented This requirement is partly outstanding from the time of the last inspection of the home Outcomes of disciplinary proceedings and additional training given to staff in relation to the administration of medication must be available for review of staff files to demonstrate appropriate action has been taken. Support plans must be reviewed and updated to contain all guidelines required to safely support a service user. Written protocols must be available to support the administration of PRN medication. Information required by schedule 2 of the care homes regulations 2001 in relation to persons working at the home must be available. The organisation must conduct an immediate review of management support and communication arrangements. A copy of the reports produced following a visit carried out in line with Regulation 26 and incidents in relation to regulation 37 must provided to CSCI This requirement is outstanding from the time of the last inspection of the home 29/05/06 7 YA20 19 (5) (b) 22/05/06 8 YA16 15 22/05/06 9 YA20 15 22/05/06 10 YA34 7,9,19 29/05/06 11 YA37 7 (1) 7 (1) 26 22/05/06 12 YA37 29/05/06 Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 26 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 YA7 Good Practice Recommendations Petty cash monitoring records should identify when service users keep the change from a transaction to reflect a clear financial audit trail and protect staff and service users from discrepancies. Bradbury Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Lodge DS0000063738.V292546.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!