Inspection on 03/08/06 for Bradley House

This inspection was carried out on 3rd August 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Bradley House 02/12/08

Bradley House 04/12/07

Bradley House 27/02/06

Bradley House 03/10/05

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Bradley House Bradley Road Grimsby North East Lincs DN37 0AJ Lead Inspector Beverley Hill Key Unannounced Inspection 3rd August 2006 09:00 X10015.doc Version 1.40 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 Bradley House DS0000065141.V295676.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bradley House Address Bradley Road Grimsby North East Lincs DN37 0AJ 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) 01472 878373 01472 277548 Dryband One Ltd Christine Angela Erbil Care Home 44 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (44), of places Physical disability (2), Physical disability over 65 years of age (2) Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Bradley House is situated close to the village of Bradley and is approximately one mile from the centre of Grimsby. The home has a view of the surrounding countryside. The home is registered to provide residential and nursing care for older people including those with dementia, physical disability over 65 years and physical disability over 18 years. In addition the home provides a respite service and provides day care services for up to six people. The home consists of two storeys, the upper floor serviced by both stairs and a passenger lift. There are thirty-six single rooms, twelve of which are en-suite and a further four large rooms situated on the first floor which can be shared or be used as single. There are three sitting rooms, one of which is for people who enjoy smoking, and two dining rooms. In addition there is a quiet room for service users to entertain their visitors in private. The home has five bathrooms on the ground floor and a shower room on the first floor. There are sufficient toilets throughout the home. The gardens to the front and side of the building are spacious and contain mature trees, shrubs and flowerbeds. The home has a small internal courtyard accessible from two separate corridors. There is also a patio area with garden furniture. According to information received from the home on 06.06.06 their weekly fees range between £329 and £510. Day care services are £30 per day. Items not included in the fee are hairdressing, chiropody and transport. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. Throughout the day the inspector spoke to nine service users and a relative to gain a picture of what life was like for people who lived at Bradley House. The inspector also had discussions with the manager, care and catering staff members, the activity coordinator and maintenance personnel. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector also checked with service users to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, family members, a selection of staff members and professional visitors to the home. They were checked and comments used throughout the report. In surveys service users and relatives were complimentary about the care provided with comments such as, ‘I am being looked after well’, ‘ I am happy for what people are doing and have done for me’ and all the relatives surveys received had ticked the box which indicated they were happy with the overall care provided. One relative had had some issues with the care provided but had addressed these with the manager and two had a perception that there was not always sufficient staff on duty. Staff members indicated they were well supported by the manager and had access to training although there were comments about the homes policy in not paying staff for the training hours they participated in on their days off. Surveys from professional visitors to the home had ticked the boxes that indicated they were satisfied with the overall care, communication was good and there was always a senior to talk to. One professional had discussed an issue with the manager and resolved it satisfactorily. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The manager completes assessments of peoples needs before they are admitted to the home and although they are told verbally that the home can meet their needs this needs to be done formally in writing to the service user or their representative. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 7 Generally care plans were well written and contained the areas that people needed support with and what they could do for themselves. However in two of the care files examined each service user had an important need that was not addressed and the daily records in some care files did not always follow on issues to the next shift. This was important, as staff must be aware of continuing care needs in order to refer to professionals or to record when a problem has been resolved. The meals were well presented and service users felt they had plenty to eat but some commented that the food was not served very hot. The inspector found this to be the case on the day. People did not seem to complain about this and now the staff members are aware they will be able to sort it out. There were some areas of the environment that needed to be sorted out. Corridor carpets and one of the lounge carpets had areas that were badly stained and two bedrooms had odours that were not pleasant for the occupants. The conservatory was out of use due to a water leak and one of the dining rooms was in need of cleaning. The courtyard area was in need of tidying up and the walkway around the house, leading to the green house would be a pleasant area for service users if cleared and made safe. Not all staff had completed mandatory training and adult protection training. This was really important to make sure that staff had the required skills to look after vulnerable older people. The home had twenty-seven care staff out of which six had completed a national vocational qualification at Level 2 or 3 in care. This equated to 22 of the care staff trained to this level and the home should be aiming for 50 . This was a slight drop since the last inspection but was due to staff leaving. However, thirteen staff members had been enrolled on the courses and when they complete it the home will exceed the target. Staff members do not receive paid training days, which can limit the incentive to participate in courses held on their days off. 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. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Five case files were examined one of which was a new admission. All had assessments of need completed prior to admission, whether funded privately or by care management. Assessments covered all aspects of health and social care. The assessments were completed by the manager and they assisted in the decision making regarding whether the home could meet service users needs. Any assessments for the nursing aspect of care were completed by the local primary care trust. One case file examined indicated that the assessment and susequent care plan addressed issues of diversity with clear routines and likes and dislikes established and when checked later these were followed through in practice. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 10 After the assessment was completed the manager informed service users or their representattives verbally that they were able to meet their needs. This must be completed formally in writing. The homes statement of purpose refers to trial visits and there was evidence of respite services in order for the service user to be introduced into the home. The home also had the capacity to support people who required day care. The manager assured that the first six weeks of admission were considered a trial period but this could be extended as required. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and social care needs are planned for and met in a way that respects privacy and dignity. Insufficient follow-on when recording daily issues could mean that important care is missed. EVIDENCE: Four care plans were examined and generally these were comprehensive and individualised focussing on specific needs with clear tasks for staff. There was evidence that they had been updated when needs changed and were evaluated monthly. Two of the care plans reflected all the information in the assessments and highlighted areas in which the service user was independent and areas where professional support was needed. One care plan did not detail specific important communication needs, although staff were aware of the needs and attempts had been made to have alternative methods of communication for the person. Daily records in some care files did not always follow on issues to the next shift. This was important, as staff must be aware of continuing care needs in order to refer to professionals or to record when a problem has been resolved. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 12 There was evidence of input from health professionals, GP’s, district nurses, community psychiatric nurses and dieticians. Comments received from professional visitors were positive about the care provided and one commented that a difficulty with staffs understanding of feeding and swallowing needs was addressed with the manager and resolved. Professionals ticked the boxes on the survey that stated they were satisfied with the overall care, communication was good and there was always a senior to talk to. Sitting scales were provided and service users were weighed monthly or more often as required. Surveys from relatives and services users generally confirmed they were satisfied with the overall care provided by the home. One person stated, ‘I am being well looked after’ and another, ‘Mum is well cared for, I’m very happy with the place’. One relative did state that she thought the care plan was not always followed but she had discussed this with the manager. Medication was managed well. It was stored, administered and recorded appropriately. Discussions with service users and some relatives indicated that staff members treated people with respect. They used their preferred term of address, knocked on doors prior to entering bedrooms and delivered personal care in a sensitive manner. Mail was delivered unopened and people were able to see visitors in private if they chose to. Staff members spoken to described how they promoted privacy and dignity by knocking on doors prior to entering and reassuring and talking to people during personal care tasks. Service users bedrooms doors had a privacy lock and some people chose to use this to lock their bedroom door when they left the room. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided flexible routines, appropriate activities and ensured people were able to make choices about aspects of their lives. The meals provided offered choice and were well presented. EVIDENCE: The home had flexible routines and visitors confirmed they were welcomed into the home at any time. One visitor commented that they felt at home coming into Bradley House and they always were offered refreshments and even a meal sometimes. A care staff member had designated hours as an activity coordinator and they organised a range of suitable activities for groups and individuals to participate in. These ranged from visiting entertainers, church services, reminiscence groups, in-house crafts and games, baking, bingo, quizzes, relaxation, movie days, seasonal parties and occasions and general chats. A monthly activity diary was displayed in the home and individual records were completed of activities participated in. One person said, ‘I don’t think we do too bad for activities’. One visitor felt that there were insufficient activities for their relative and when checked the person had participated in four activities in July. It would be useful for the activity coordinator to have an Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 14 ‘at a glance’ record of the amounts of activities people are participating in, in order to tailor the programme or build in more one to one support. Service users spoken to stated that they were able to make choices about certain aspects of their lives and cited times of rising and retiring, meals, activities and going out with visitors as examples. Some service users had their own telephones, Sky TV and fridges installed and bedrooms were personalised according to individual choice and taste. One service user was very independent but had chosen to live at the home rather than on their own. They used local facilities as they chose. Some people chose to smoke and the home had a separate lounge to accommodate this. Service users spoken to were happy with the menus and stated they had enough to eat and drink. The home had two choices for the main and evening meals and a variety of breakfast options. One person stated, ‘I like to have sugar puffs in the mornings followed by a bacon sandwich and I always have a bitter with my lunch’. Another service user said, ‘the food is excellent, good plain cooking’. One person did comment that the plates were not warmed and this cooled the food too quickly and was not as hot as they would like it. This was mentioned to the staff to address. The food server had a broken temperature dial but catering staff said they used a food probe to check the temperature prior to serving. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users felt able to complain and knew who to complain to. The home protects service users from abuse by training staff, good recruitment and adherence to policies and procedures. However not all staff had received adult protection training. EVIDENCE: The home had a complaints policy and procedure that detailed timescales for resolution and referral to other agencies if not satisfied with the homes investigation. A complaint form was used that detailed a description of the complaint, any action taken, and follow up required. It had scope to verify the effectiveness of the action and to review issues with the complainant. The manager signed off the form on completion. There had been two complaints since the last inspection and these were dealt with appropriately. The Commission had also received a complaint about an odour in one of the bedrooms and carpets in corridors that were stained. These points in the complaint were upheld. Service users spoken to stated they would go to the registered manager (they knew her name) if they wanted to complain. This was an indication that the manager was visible and approachable to people. A relative present during the inspection was also familiar with the complaints process but stated they had not had to use it. The complaints procedure was on display within the home. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 16 The home had an adult protection policy and procedure and the manager was familiar with the referral and investigation processes required should they be any allegations of abuse reported to them. The home had a copy of the local authority multi-agency policy and procedure. Not all staff had completed training in the protection of adults from abuse although some had seen a video. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some areas of the internal and external environment fall short of requirements and this means that service users live in an environment that in parts is inadequate for their needs. EVIDENCE: Service users spoken to were able to personalise their bedrooms and this was seen to varying degrees. Some people had chosen to bring in their own items of furniture, pictures and ornaments, a telephone etc and one person had installed their own fridge. Since the last inspection privacy locks, checked by the fire department, had been fitted to bedroom doors for service users to lock behind them when they left the room. Some people had taken up this option. Maintenance staff recorded the temperature of hot water outlets in bedrooms, bathrooms and toilets and some of these were on the cool side ranging from 37°C to 41°C. They were in need of adjusting to a more ambient temperature of 43°C Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 18 Carpets in corridors were badly stained and in need of deep cleaning or replacement. Parts of the carpet in one of the lounges were also in need of shampooing. The manager confirmed that the shampooer had been broken and a new part had been required. There were also two bedrooms that were malodorous and a discussion about one of these was required with the service user and relatives regarding the possibility of alternative flooring to address the problem. The conservatory had sustained a water leak and was unusable at the time of inspection. This had occurred three weeks previous and must be addressed so service users can enjoy the benefits of it. One service user advised the inspector the room was out of order and they missed not being able to sit in it. The space was also calculated as part of the overall space allocation required within the home for each service user. The dining rooms were both in need of a general clean. The carpet in one had not been cleared of breakfast debris at almost lunchtime and the linoleum floor and individual tables and place mats in the other room were in need of cleaning. This second dining room also looked quite institutional although the manager stated it was due for redecoration and freshening up. The windowsills and paintwork were grimy and one of the windows was cracked. One or two of the dining tables in the carpeted dining room were a little unsteady and in need of minor attention. The external grounds at the front of the house had been attended to and the borders tidied up. The home had a courtyard area with seating accessed from one of the corridors and this led onto a walkway almost all the way around the back of the home and to a green house. This area was quite neglected and service users were unable to access it safely. This meant that there was not a safe area externally for service users if they were unaccompanied. The manager spoke about the new proprietors plans to address this situation and to utilise the external grounds more effectively. The driveway remains pebbled, which makes wheelchair access difficult. The environmental issues needs to be added to the refurbishment and redecoration plan with timescales for completion. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensured their recruitment of staff was sufficiently robust to protect service users. Not all staff members had completed relevant training. EVIDENCE: There were sufficient staff members in terms of numbers for the amount of service users admitted to the home but the dependency levels of some service users were quite high and some staff felt they were constantly rushing around. These dependency levels do fluctuate and the manager was aware of the situation. She was in the process of addressing the bathing routines organised for service users to ensure staff members were not so rushed in the mornings but the choices and wishes of service users were still respected. There were six care staff members and one nurse in the morning, five and a nurse in the afternoon and three and a nurse at night. The manager was generally supernumerary but does work the occasional shift. Two out of five surveys received from relatives felt that there were insufficient staff members on duty all the time but all felt welcomed into the home, were kept informed and were happy with the overall care. Five surveys were received from service users and all stated they received the care and support they required and they were listened to ‘always’. Four felt that staff members were available ‘always’ and one stated ‘sometimes’. People spoken to were complimentary about the staff, ‘they are patient’, ‘very good’, and ‘if I ring the Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 20 bell they are there quickly’. A comment in one survey said, ‘ I am being looked after well, I am happy for what people are doing and have done for me’. The manager recruited staff appropriately and correct documentation was obtained prior to the start of employment. The home maintained an individual training record for each staff member and used a selection of training methods. These included external facilitators, inhouse trainers, distance-learning booklets, videos with questionnaires and access to local authority training courses and those provided by health professionals. All staff had completed moving and handling training and the company had staff trained to deliver this. Some staff had accessed courses on nutritional screening, diabetes, stroke, Parkinson’s disease and dementia awareness and although qualified nurses administered medication some care staff had completed an accredited medication course for their own development. Generally staff felt they received the training they required and it was recognised that this was an ongoing process. Not all staff had completed mandatory training and adult protection training. The home had twenty-seven care staff, out of which six had completed NVQ at Level 2 or 3 in care. This equated to 22 of the care staff trained to this level and the home was aiming for 50 . This was a slight drop since the last inspection but was due to staff leaving. However, thirteen staff members had been enrolled on the courses and when they complete it the home will exceed the target. Staff members have commented that any training courses provided on their day off has to be attended and they do not receive remuneration for this. This has the potential to affect motivation to complete training and should be addressed by the proprietor. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was generally well managed and staff training and adherence to policies and procedures promoted the health, safety and welfare of service users. EVIDENCE: The manager is a Registered Nurse and has completed a certificate in management. Service users, staff and relatives described the manager as very approachable. Since the last inspection the manager had continued to build on the systems they had in place to manage the home. Staff members were consulted during meetings and they received formal supervision as per requirements. Those staff members spoken to and staff surveys received indicated that they felt supported by the manager. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 22 Service users personal allowance, when managed by the home, was recorded appropriately on individual record sheets and maintained by administration personnel. Lockable facilities were available for people who wished to manage their own finances. Documentation highlighted that there had not been any service users meetings for some time although consultation about the services the home provided had started to take place in the form of questionnaires for the homes quality assurance process. The staff team participated in quality assurance and audits were completed on systems within the home such as complaints, accidents, care plans, medication, the treatment room and the kitchen. The new quality monitoring only started in May so was in the early stages. To date a survey on the laundry service had been completed and an action plan was produced to address the shortfalls. Other surveys were planned during certain months of the year and although not completed yet staff members, relatives and professional visitors to the home were surveyed for their views. This process brought the home quality assurance system into line with the company’s other homes. General and individual risk assessments were completed and updated and during the inspection an external consultant visited the home to review the fire risk assessment. Maintenance staff completed records of equipment servicing and carried out weekly, fortnightly and monthly checks and alerted the manager when repairs were required. Bradley House DS0000065141.V295676.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 2 1 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 3 X 3 Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP18 Regulation 13(6) Requirement The registered person must ensure that all staff receive training in the protection of adults from abuse. (Previous timescale of 31/05/06 not met although some progress has been made) Timescale for action 31/10/06 2. OP30 18 The registered person must 31/12/06 ensure that all staff members complete mandatory training and updates. (Previous timescale of 30/06/06 not met, although some progress has been made) The registered person must continue the start made to the quality assurance process and ensure action plans are reviewed for effectiveness. Results of surveys to be forwarded to the CSCI. (Previous timescale of 30/04/06 partially met) 31/12/06 3. OP33 24 4. OP3 14(1)(d) The registered person must 30/09/06 ensure that service users or their representatives receive formal written confirmation that the DS0000065141.V295676.R01.S.doc Version 5.2 Page 25 Bradley House 5. OP7 15 6. OP19 23 7. OP25 23 8. OP26 23 9. OP32 12 (2)(3) home, taking into consideration the assessment, is able to meet their needs. The registered person must ensure that the specific assessed communication needs of one service user are addressed in their care plans and recording of daily care follows on consistently from shift to shift. The registered person must ensure that the courtyard area, the pathway surrounding the home and the conservatory are made safe for service users to use. The one or two tables in the dining area that are a little unsteady to be made secure. The registered person must ensure that hot water outlets that record a low reading are adjusted to a more ambient temperature of 43°C. The registered person must ensure that the corridor carpets are cleaned or replaced, the dining room cleaned and odours in two bedrooms eliminated. The manager must ensure that service user consultation is increased by restarting service users meetings or smaller group discussions to run along side the quality assurance programme. 15/09/06 13/10/06 15/09/06 30/09/06 30/09/06 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 OP12 Good Practice Recommendations The Activity Coordinator should maintain ‘at a glance’ information of who has not participated, or who has only DS0000065141.V295676.R01.S.doc Version 5.2 Page 26 Bradley House participated seldom, in activities in order to investigate the reasons and make adjustments to the programme. 2. 3. OP28 OP26 The home should continue to work towards 50 of staff trained to NVQ Level 2. The manager and proprietor should discuss with the service user and their relative the need for alternative flooring in one bedroom. Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Bradley House DS0000065141.V295676.R01.S.doc Version 5.2 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. 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