Inspection on 03/10/05 for Bradley House

This inspection was carried out on 3rd October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 03/08/06

Bradley House 27/02/06

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 Unannounced Inspection 09:30 3 October 2005 rd 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.V270268.R01.S.doc Version 5.0 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.V270268.R01.S.doc Version 5.0 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.V270268.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13/01/05 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 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 that appeared to be a suntrap. There is also a patio area with garden furniture. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The CSCI and Social Services each received an anonymous complaint at the same time regarding allegations of financial abuse of one service user and poor moving and handling techniques, both incidents alleged to have been completed by a particular staff member, who was suspended pending investigation. The allegations were investigated by the Police, a Social Services care manager and a CSCI regulation inspector. Staff members and service users were interviewed, documentation was examined and CSCI completed an inspection during the five visits to the home. During the course of the investigation the manager advised that a staff member had been dismissed for swearing at a service user. The sale of the home had just been completed and the new owner was made aware of the incidents, which are alleged to have occurred in December 2004 (moving and handling) and, over a period of time but up to February 2005 (financial abuse). The findings from the investigation into the moving and handling allegation, the swearing at a service user and other issues that came to light can be found in the section on complaints and protection. Police Officers are still investigating the financial abuse allegation. The home received requirements during the first two visits and these were checked out at the next visit and were met. They have all been included in the final requirements at the end of the report. What the service does well: There was a group of nurses and care staff that had worked at the home for several years and knew the service users well. Some people who lived at the home said that the staff members were caring, looked after people well and made their relatives feel welcomed. The allegations mainly centred around one staff member. On the whole the home makes sure that all the care people need is written down in care plans so that staff are aware of how to support people. Service users and two relatives spoken to were very complimentary about the meals provided. The home always made sure that people had an assessment prior to being admitted to the home. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 6 The home provided a pleasant environment and had a welcoming, homely feel. It was clean and tidy in communal areas, although the carpets in corridors were in need of cleaning. There were areas throughout the home where people could sit quietly. What has improved since the last inspection? What they could do better: The staff did not always write down all the care that they provided and sometimes they did not make sure that daily records followed on to the next shift. This was important because care issues that staff noticed one shift or day would need to be monitored the next. Some personal care tasks were not completed fully for one person. This was not acceptable and left the person not able to reach their drink and call bell. The staff did not really document all the complaints and concerns they received although they tried to sort them out straight away. These need to be written down to show how they are dealing with them and that the complainant is satisfied. The manager did not report allegations of poor moving and handling and swearing at a service user to the right agencies but investigated the allegations herself. This was not following appropriate policies and procedures and could place people at risk of harm. A small number of bedrooms had an unpleasant odour. The carpets in the corridors need to be cleaned and the driveway could be made more accessible to wheelchair users. The home could check out with people whether they want locks on their bedroom doors and fit them if they do. If they don’t they could fit them as standard when the room becomes vacant. This would give people extra privacy if they choose. The home could improve the staffing at night to make sure there is always enough care staff on duty. Not enough staff on duty could place people at risk of inadequate care. The manager needed to make sure staff were supervised properly and discussions about discipline written down. Communication between staff needed to improve and some staff needed to be more professional in their approach and language. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 7 In two instances previous staff who were re-recruited to the home after a sixmonth absence did not have all the documentation and checks made on them. This was important to protect people who lived at the home. 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.V270268.R01.S.doc Version 5.0 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.V270268.R01.S.doc Version 5.0 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 Service users had an assessment of their needs completed prior to their admission to the home. EVIDENCE: There was evidence of in-house assessments of service users needs prior to their admission to the home. The home used a spandex system of assessment and care planning and these were completed in the care files examined. The documentation covered a whole range of physical, psychological, emotional and social needs. The manager completed assessments on service users admitted for nursing care and the care manager for those people admitted for residential care. The home obtained assessments completed by care management prior to admission. The assessments were important as they provided vital information for the care planning stage and also determined whether the home could meet the service users needs. Any assessments for nursing care were completed by the local primary care trust. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 10 Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 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 and 10 Generally care plans reflected peoples needs but shortfalls in some elements of personal care, daily recording and in one case inappropriate language were noted. These shortfalls have a potential to place service users at risk. EVIDENCE: Four care plans were examined in detail and others perused. Care plans detailed assessed needs and had clear tasks for staff. There was evidence that they were updated when needs changed. The home used a range of risk management tools, for example nutritional screening, pressure area care, moving and handling, dependency assessments that were reflected in care plans. There was evidence that these were updated monthly. Care files included input from health professionals, for example GP’s, district nurses, dieticians and speech therapists etc. There was evidence that service user or their representative had signed some of the care plans. The daily progress notes were basic and did not give a full picture of the care provided over the full day and night, nor followed on consistently issues Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 12 highlighted during one shift to the next. This is important as it means that care may be missed. There were some elements of personal care that needed to be addressed. One service user spoken to during the visits had received a shave with an electric razor. This had not been completed fully and he stated he preferred a wet shave but staff were ‘a bit busy’. His nails were also noted to be dirty, the wrong cup had been placed on his table (he was unable to lift it properly due to arthritic hands) and his call bell and drinks bottle were out of reach. The service user clearly had not received the support he required that morning. The service user explained that he usually sat in the conservatory but was sitting in his bedroom that morning because the air conditioning was not working properly and it was very hot. He stated that care was provided in a ‘nice way’ respecting privacy and dignity. One service user stated that staff did not always carry out his personal care tasks effectively, that is washing and drying him properly. He stated he had not complained about this to anyone although he had complained about other things such as call bell response times and staff not using a moving belt on him. Other people spoken to confirm that staff members respected their privacy and dignity by knocking on the bedroom doors, were polite (very important for one person) and were sensitive during personal care tasks. However there was evidence that service users’ dignity had been compromised by the use of inappropriate language. Although service users themselves did not confirm this, staff members who had witnessed the incident did confirm it. During the visits the inspector noticed a sign on the external side of one of the service user’s bedroom doors. It had inappropriate and offensive language and was visible for other service users and visitors to see. The service user had chosen to place it there and staff had added various inappropriate comments. The sign was more appropriate for the inside of the bedroom and this was discussed with them. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 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): 13 and 15 The home encouraged service users to maintain contact with their family and friends and provided a well-balanced menu that met people’s nutritional needs. EVIDENCE: A number of service users and two relatives spoken to confirmed that there were no set times for visiting and visitors were always made to feel welcome. One person who visited every day by choice to help their relative to eat their lunch praised the staff for the welcome and stated they were always kept informed. They were offered refreshments and something to eat when they visited. The visitor book showed that people signed in and out and the service users received plenty of visits from relatives and friends. The home had maintained some links with the community. Local schools and the Salvation Army visited at Christmas and the library visited every three months to exchange books and videos. One service user continued to access an external club and entertainers visited at regular intervals. The home provided four-weekly rotating menus. There were two choices at lunch and alternatives at teatime. There was evidence that the cooks catered for special diets such as diabetics, low fat and those with allergies. Service users spoken to were complimentary about the food, ‘ its very good, you get Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 14 lots to eat’, ‘ there are choices at each meal and you get plenty’, ‘lovely’, ‘exceptional, you get choices and it’s hot’ and ‘I’m very happy with the food’. One person stated that they were allergic to dairy products and after a while the home got it right and “it’s great”. One relative spoken to stated their loved one had lost weight during a stay in another home but had regained that weight since admission to Bradley House. She felt this was due to the diet and care received. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 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 The home did not document all concerns as complaints, when received from staff, and did not complete the complaint form fully in all cases. The home failed to protect one service user from injury and put service users at risk by poor moving and handling. Despite awareness of adult protection policies and procedures the manager failed to use them and report incidents to the Adult Protection team, placing service users at further risk. EVIDENCE: The home had a complaints policy and procedure that detailed timescales for resolution and referral to other agencies if not satisfied with the home’s 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 five formal complaints since the last inspection, one of which was investigated by care management. The outcome was not documented but the inspector was aware that the outcome of this complaint was upheld and related to care received during a service user’s respite stay. During interviews some staff stated that they had discussed issues or concerns with the care manager and on occasions the registered manager/matron but these had not been documented and they had not received any feedback. It was apparent that some concerns had not reached the manager through a breakdown in communication. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 16 A relative spoken to stated they had made a complaint about a poor flushing toilet and this was sorted out straight away. Both relatives and service users spoken stated they would go to the registered manager/matron (they knew her name) if they wanted to complain. This was an indication that the manager was visible and approachable to people. The manager had investigated a complaint received anonymously from staff in November 2004 that related to moving and handling techniques of some staff and some staff swearing in front of service users. The staff member denied moving and handling alone and without equipment but during interviews with staff the incidents of moving and handling alone and some staff swearing in front of service users were confirmed. The inspector could find no record of any disciplinary measures taken about the moving and handling incident and it was not discussed in the person’s supervision. The manager dealt with this via a staff meeting reminding all staff to move and handle appropriately and further training was provided. The protection of vulnerable adults policy was discussed with staff in supervision. There was one record of a verbal warning to a staff member for swearing on the floor, however in discussion with that staff member they had not received any written information about the warning and did not appear to know they had received one. The moving and handling incident caused bruising to one service user and upset another and this should have been referred to the Adult Protection Team for investigation and should not have been investigated by the manager. The complaint form completed had no date on, had not been signed off by the manager and had not had the action taken verified for effectiveness. An accident form for the bruising was not completed. The investigators interviewed staff and all stated that they had received moving and handling training and now moved and handled service users in the correct way. Service users spoken to mostly confirmed this, however one service user stated that the staff did not always use the moving and handling belt with them. When discussed with the manager it transpired that the person’s mobility fluctuated daily and staff made a mental assessment to their weight-bearing capabilities each time. However staff should always use the moving belt and the manager will address this. An immediate requirement notice was issued. During the visits the manager informed the investigators that a staff member had been dismissed for gross misconduct. Another staff member had witnessed them swearing at a service user. The staff member had walked out but the disciplinary process went ahead. Again the manager should have referred this to the Adult Protection Team instead of investigating the incident herself. The manager must be aware of what constitutes referral to the Adult Protection Team and must follow policies and procedures in this area. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 17 Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 18 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 and 26 Generally the home provided a comfortable and safe environment for service users, however areas of the environment affected some service users’ comfort and access to the home. EVIDENCE: The home was a mixture of old and new buildings, had wide corridors with handrails and was suitable for its intended purpose. During a tour of the building the inspector noted an odour in some of the bedrooms. This was mentioned to the manager to address. The conservatory was not in use during some of the visits as it was exceptionally warm and the portable air conditioning unit was of an insufficient size for the room. The carpets in the corridors, and in one or two bedrooms, were stained and in need of cleaning. The paintwork in the corridors was quite chipped in places. The manager advised that the new owner had added the replacement of carpets and new air conditioning for the conservatory to the refurbishment list he was in the process of drawing up since he took over ownership. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 19 The garden and courtyard areas were in need of tidying and weeding and the driveway was pebbled and was uneven in places. They driveway was difficult for service users in wheelchairs to access. Generally the home was clean and tidy and the bedrooms examined showed they were personalised to varying degrees. Some of the bedrooms did not have lockable facilities and most did not have privacy locks. However the manager confirmed that these were available on request. There was evidence that one service user had requested a lock to their bedroom door and this had been provided. People spoken to were happy with their bedrooms. The inspector suggested that privacy locks be fitted as standard to bedroom doors as the rooms become vacant. Staff must easily access locks in an emergency. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 20 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 and 29 There were insufficient staff members on duty during some night shifts, which could place service users at risk of inadequate care. Inconsistent recruitment practices could place service users at risk. EVIDENCE: It was noted that new staff were recruited in accordance with policies and procedures and two files examined detailed all the required checks had been completed including Criminal Records Bureau checks. However two staff members had left the home and returned very recently after a six-month gap. The staff members were re-instated as opposed to recruited in the correct way. References from their employer in the interim had not been sought and a new Criminal Records Bureau check had not been completed. This potentially placed service users at risk. The inspector examined a four-week rota that showed who was on duty and in what capacity. During the morning there were five carers, one senior carer and one nurse, in the afternoon, four carers, one senior and one nurses and at night three carers and one nurse. The home had a care manager and the registered manager. There appeared to be sufficient domestic and catering staff. Following the inspection visit, a complaint was made regarding the numbers of staff at night. The proprietor investigated the complaint and found that not all Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 21 night shifts had the required three care staff on duty with the nurse. Staff sickness and short notice absences was highlighted as the main cause and the manager was to address this through disciplinary means and further recruitment. Two service users stated that they sometimes had to wait a long time for call bells to be answered but other people spoken to said response times were generally quick. This was mentioned to the manager to check out periodically. A relative spoken to stated, ‘the staff are very nice and informative; yes they always keep us informed. I’m invited to reviews and if I don’t attend they always send me the minutes’. Another relative stated that the care was very good and the staff were, ‘lovely’. They visited the home on a twice-daily basis. Service users commented that staff, ‘sometimes are too busy to stop and talk but they are lovely’, ‘they are kind and polite’, very good’, ‘helpful’ and ‘no problems at all’. During the visits certain issues regarding poor professional attitudes of some staff members was highlighted. For example, staff colluded in an inappropriate notice placed on a service users bedroom door, some purchased cigarettes from a service user who had obtained them from a dubious source, staff members have sworn in front of service users and one staff member was heard to swear at a service user and was dismissed. Professional attitudes must be encouraged at all times. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 22 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, 35, 36 37 and 38 Deficiencies in the management of a service users’ finances, staff supervision and recruitment, documentation relating to staff discipline, communication between the care manager and registered manager and the reporting of concerns and allegations of abuse to outside agencies has placed service users at risk. EVIDENCE: The manager is a Registered Nurse and is described by service users and relatives as very approachable. However there have been some deficiencies in management systems that need to be addressed. See below. In the main the families of service users or solicitors managed their finances, however the home supported one service user to manage their finances, and this had not been completed as robustly as it should. Records and receipts of goods purchased on his behalf were only recently maintained. The service user was able to visit the shops with support to make their own purchases and this Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 23 should be encouraged. The police were investigating an allegation of financial abuse by a staff member, who had been suspended. The home’s residents’ fund was checked and the amount did not tally with the record. The administrator audited the account shortly after the inspection and the discrepancy was located and rectified. Staff supervision was taking place but was inconsistent. Some staff had not received any supervision at all. When supervision did take place it was formal, documented and included discussions on care practices, policies and procedures, key worker role and staff training needs. Discussions of a disciplinary nature were not documented and the procedure not fully followed. Not all notifiable incidents have been recorded as such and forwarded to the CSCI as required. The manager or senior staff member on duty must be aware of what needs to be reported to other agencies. The investigation highlighted that staff members had moved and handled service users without equipment, which was unsafe for both the service user and the staff member. One service user sustained bruising but this was not documented in the accident book. Although the incidents had occurred last year one service user had since been transferred intermittently without a moving belt. Also one bed was noted to have a bedrail with a limited safety height due to a specialist mattress. These two issues posed unnecessary risks and immediate requirement notices were issued for staff to follow risk assessments and moving and handling guidelines and to review the bed rail. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 24 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 x x x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x x x 1 1 2 2 Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 25 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 OP29 Regulation 19 Requirement The registered person must ensure that two references are obtained prior to employment (previous timescale of 13/01.05 not met) The registered person must ensure that all care staff members receive formal supervision at least six times a year (previous timescale of 13/01/05 not met) Those who have not received supervision to have the first session by timescale for action date. The registered person must ensure that daily recording reflects the care given and follows on issues to the next shift. The registered person must ensure that personal care tasks are monitored and completed to the service users satisfaction and documented. The registered person must ensure that moving and handling care plans and risk assessments are followed. DS0000065141.V270268.R01.S.doc Timescale for action 03/10/05 2 OP36 18(2) 30/09/05 3 OP7 12(1)(a) 31/12/05 4 OP8 12(1)(a) 31/12/05 5 OP8 12(1)(a)& 13(4) 03/10/05 Bradley House Version 5.0 Page 26 6 OP10 12(4)(a) 7 OP16 17(2) 8 OP18 13(6) 9 OP19 23 10 OP26 23(2)(d) 11 12 OP27 OP27 18(1)(a) 12(5)(b) 13 OP29 19 14 OP31 10(3) 12(1)(a) The registered person must ensure that the privacy and dignity of service users is maintained at all times. The registered person must ensure that all concerns from service users, relatives and staff are documented fully as complaints to provide clear audit trail of action and complainant satisfaction. The registered person must ensure that the registered manager follows adult protection policies and procedures regarding referral and investigation. The registered person must ensure that a refurbishment plan with timescales is completed that addresses environment issues such as carpets in corridors and one bedroom, the driveway, garden and courtyard areas and some paintwork. Plan to be produced by timescale for action date and forwarded to CSCI. The registered person must ensure that the odour in the bedrooms is investigated and eliminated. The registered person must ensure the correct number of care staff at night. The registered manager must ensure that professional relationships are encouraged and maintained between staff and service users The registered manager must ensure that when staff are rerecruited to the home after an absence and employment elsewhere, full recruitment checks take place. The registered manager must ensure that communication and DS0000065141.V270268.R01.S.doc 03/10/05 03/10/05 03/10/05 31/01/06 06/01/06 03/10/05 03/10/05 03/10/05 03/10/05 Page 27 Bradley House Version 5.0 15 OP35 17(2) schedule 4(9) 20(3) 16 OP35 17 OP36 12(1)(a)& 18(1)(a) 37 18 OP37 19 OP38 12(1)(a) documentation skills are improved to ensure the effective management of the home. The registered person must ensure that the residents fund is audited and the discrepancy located. This was rectified the following day. The registered person must ensure that policies and procedures regarding the management of service users finances are reviewed and followed by staff. The registered manager must ensure that staff disciplinary measures taken are documented and acted on as per procedures. The registered person must ensure that all notifiable incidents are recorded and forwarded to the CSCI. The registered person must ensure that the health and welfare of service users is maintained by documenting accidents, correct moving and handling and risk assessing the height of bedrails in one bedroom. 03/10/05 03/10/05 03/10/05 03/10/05 03/10/05 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 OP24 Good Practice Recommendations The proprietor should fit privacy locks as standard when bedrooms become vacant. Bradley House DS0000065141.V270268.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 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. 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