CARE HOME ADULTS 18-65
Bradmere 16 Franklin Street Patricroft Eccles Gtr Manchester M30 0QZ Lead Inspector
Val Bell Unannounced Inspection 22nd September 2005 10:00 Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 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 Bradmere DS0000008343.V252814.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 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. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bradmere Address 16 Franklin Street Patricroft Eccles Gtr Manchester M30 0QZ 0161 787 8631 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) Mrs Joan Rawlinson Mr Bradley Rawlinson Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 4 named individuals have a physical disability in addition to a mental disorder. 10th February 2005 Date of last inspection Brief Description of the Service: Bradmere is a care home providing personal care and accommodation for up to 12 adults with enduring mental ill health. The home has good links with the Forensic Psychiatric Service and provides accommodation to some people who have mental health needs and a forensic history. Admission for people with these needs is dependent upon a thorough assessment of risk. In addition, the home is able to provide a service for up to four named individuals who have a physical disability in addition to mental health needs. The main aim of the home is to provide a rehabilitation service for younger adults who have experienced a period of hospitalisation. Long-term care is provided dependent on the assessed needs and aspirations of the individual resident. Bradmere forms part of the Bradmere and Merrymeet Care Group, which includes a second care home and a domiciliary care agency. The home is situated in the Eccles area of Salford, close to local shops, pubs and public transport routes. The home is a large modern style house with car parking at the front and a pleasant garden at the rear. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during the day on 22 September 2005. During the inspection records were examined, a tour of the premises was undertaken and conversations were held with residents, staff and management. Ten residents were living in the home on the day of inspection. Four of the five requirements made at the previous inspection had been addressed. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 6 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 Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 7 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): 1 and 2 Thorough assessments of need and introductory visits ensure that prospective residents are able to make informed choices on whether the home is suitable to meet their needs and preferences. EVIDENCE: Although the homes Statement of Purpose and Service User Guide had been reviewed and updated since the previous inspection, this did not include information relating to the recent addition of a conservatory. Residents had received thorough assessment of their needs prior to making a decision on whether to move into the home. A prospective resident had visited the home the day prior to the inspection. The inspector was told that the individual would be invited for several further visits, which would include joining residents for meals and overnight stays. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 8 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, 8 and 9 Failure to undertake regular care plan reviews potentially placed residents at risk of not having all their changing needs met. EVIDENCE: Each resident had a care plan and appropriate risk assessments that had been drawn up from assessments of need. There was evidence that resident’s changing needs had been re-assessed and that action had been taken to update care plans where necessary. However, one of the care plans examined had not been updated since February 2004. Although the inspector was told that reviews had been held for this resident, the records could not be located during the inspection. Where care plan reviews had been undertaken, there was evidence that resident’s relatives and the relevant professionals had been invited to attend. Throughout the inspection residents were observed to fully participate in the day-to-day running of the home. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 9 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): 11, 12, 13, 14 and 16 Residents living in the home were confident that staff would provide the appropriate level of support to enable them to maximise their self-confidence and independence. EVIDENCE: One of the resident’s had been able to develop her independence to the point where she had recently moved into her own flat. It was commendable to note that staff at the home, were continuing to offer regular support and encouragement to this individual. Throughout the inspection residents were observed to carry on their preferred lifestyles by engaging in community activities such as shopping, visiting friends and local amenities. It was noted that there was a very relaxed atmosphere in the home and all the residents were confident in conversation with the inspector. A newly admitted resident said that moving into the home had opened up a new world for him as he was encouraged by staff to develop his self-confidence and independence. This resident had taken responsibility for
Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 10 keeping the garden area free of weeds and he spoke of his plans for developing the garden’s appearance. Care plans examined, contained individuals preferences for activities of daily living and these had been developed into structured schedules, with residents involvement. One of the residents told the inspector that they were going on a trip to Blackpool that evening. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 11 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 and 19 Staff ensured that residents’ healthcare needs were being met by enabling their access to the full range of community healthcare services. EVIDENCE: Care plans contained detailed information relating to the healthcare needs of residents. These needs were being met by prompt referral to the relevant healthcare professionals. Staff were available to attend outpatient appointments with residents where necessary. The manager accompanied one of the residents to a psychiatric review on the day of inspection. During the inspection staff were observed to consistently offer reassurance to residents where necessary. Residents said that they were confident in seeking guidance and advice from staff if they had any worries or concerns. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: None of the Standards in this section were assessed on this occasion. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 13 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, 26, 27, 28 and 30 High standards of décor, furnishings and fittings and regular maintenance of equipment provided residents with a safe and comfortable living environment. EVIDENCE: On a tour of the home the premises were found to be exceptionally clean, hygienic and fresh smelling. Credit for this was given to the member of staff who had responsibility for managing the domestic provision. The home received a commendation for this as an area of best practice. At the time of inspection the home was undergoing a programme of redecoration. A conservatory had recently been added to the home. This increased the available communal space and provided a pleasant seating area for residents overlooking the rear garden. The conservatory also provided a useful area for residents and staff meetings. Several items of furniture and equipment had been replaced since the last inspection including dining room chairs, a window blind, security lights at the rear of the house and hand towel dispensers. The inspector was told that the kitchen was due to be re-furbished. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 14 Residents said that they were proud of the quality of their environment and it was evident that they took a great deal of interest in it. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: None of the Standards in this section were assessed on this occasion. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 16 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, 42 and 43 Failure to produce evidence of insurance cover potentially placed residents, staff and visitors to the home at risk of not having their legal rights protected. EVIDENCE: The manager had not yet enrolled on a course of study to achieve NVQ level 4 in care and management. A requirement was made accordingly. No health and safety issues were identified during this inspection. The certificate of public liability insurance (PLI) on display had expired in May 2005. The inspector was told that this insurance had been renewed although the current certificate could not be located during the inspection. A current PLI certificate must be displayed at all times. Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 4 X 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bradmere Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 2 DS0000008343.V252814.R01.S.doc Version 5.0 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement The Statement of Purpose must be reviewed and updated to include information relating to the addition of a conservatory. Care plans must be subject to regular review. The registered manager must demonstrate that he has the qualifications and skills necessary to manage the care home. A current certificate of public liability insurance must be displayed within the home at all times. Previous timescale of 10/05/05 not met. Timescale for action 22/11/05 2 3 YA6 YA37 15 9 22/11/05 31/12/05 4 YA43 25 (2) (e) 22/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bradmere DS0000008343.V252814.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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