CARE HOME ADULTS 18-65
Bradmere 16 Franklin Street Patricroft Eccles Gtr Manchester M30 0QZ Lead Inspector
Val Bell Unannounced Inspection 7th March 2006 10:00 Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 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.V280797.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 4 named individuals have a physical disability in addition to a mental disorder. 22nd September 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.V280797.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted during daytime hours on Tuesday 7th March 2006. This report should be read in conjunction with the inspection report of 22nd September 2005. During this inspection various records, including care plans, were examined and conversations were held with staff, management and residents. Three of the four requirements made at the previous inspection had been met. What the service does well: What has improved since the last inspection?
The Statement of Purpose had been reviewed and updated to ensure that accurate information was available to residents and their representatives/ The requirement made at the last inspection for the home to display a current certificate of public liability insurance had been met. The registered manager demonstrated a commitment to his ongoing professional development by enrolling on an NVQ level 4 course in management. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 6 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.V280797.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Prospective residents are given enough information to enable them to make a decision on whether the home is the right one for them. EVIDENCE: Since the previous inspection the homes Statement of Purpose had been subject to formal review. The document had been updated to include the addition of a conservatory, for use by residents and staff training details had also been included. A conversation was held with a resident who had recently been admitted to the home. He told the inspector that he had received adequate information that had enabled him to decide if the home was the right place for him. He felt that it had been a good move and that he was settling in well. He was keen to develop his self-confidence and aimed to eventually attend a local resource centre where he could meet people and get involved in activities. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Care plans were not up to date. Consequently the home could not provide evidence that the current needs of residents were being met. EVIDENCE: Little progress had been made on reviewing and updating care plans as required at the previous inspection. The manager stated that he was planning to undertake care plan reviews in the coming months and that the reviews would be done in consultation with residents, their representatives and support staff. The outstanding requirement was re-iterated in this report. Conversations regarding decision-making were held with three residents. These three residents confirmed that they were encouraged to make their own decisions and said that staff were always available to offer support and guidance if needed. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 10 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): 15 and 17 The provision of a well-balanced and nutritious diet promoted the health and welfare of residents. EVIDENCE: Residents confirmed that they were able to received visitors into the home and one resident said that they regularly visited a relative. One of the residents had recently suffered a family bereavement and the home had had arranged the appropriate bereavement support by liaising with relevant social and healthcare professionals. Residents said that they were consulted about the homes menus at their regular meetings. The menus demonstrated that the home provided wellbalanced and nutritious meals for residents. Fridge, freezer and food temperatures had been recorded regularly. The manager stated that the kitchen units were due for a full refurbishment. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 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): 20 Incomplete medication administration records potentially places the health and welfare of residents at risk. EVIDENCE: A discussion was held with a resident who had some health concerns. He told the inspector that staff had made an appointment for him to see his doctor that afternoon. He added that staff had given him advice regarding his smoking habits as it was felt that this was contributing to his health problem. One of the residents was self-medicating and had been provided with a secure facility to lock his medication away in his room. The medication administration records (MAR) were examined and it was found that these were generally kept up to date. However, several gaps were noted. No explanation for the non-administration of medication had been made on the MAR sheets. Additionally, the medication received into the home for two residents had not been signed in as correct. It was also required that a list of signatures of staff authorised to administer medication is included in the medication records.
Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 12 The manager stated that he would undertake update medication for all the staff. The homes medication procedure was very comprehensive and a log of medication returned to the pharmacy was held. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Robust procedures for dealing with complaints and allegations of abuse afforded protection to residents’ welfare. The practice of involving residents in staff training sessions develops individuals’ knowledge of their rights and encourages them to be self-determining. EVIDENCE: The home had not received any complaints in the previous twelve months. A new complaints recording format had been introduced and this included a very detailed action plan for resolving complaints. It was noted that the home had received a letter of compliment from a Tameside contracting officer. Robust procedures for the protection of vulnerable adults were in place at the home. A course on the awareness of abuse had been booked for the end of March 2006. Residents had been invited to attend this course along with support staff. This is considered to be an area of best practice and was commended. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: None of the Standards in this section were assessed on this occasion. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 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): 32, 34 and 35 Residents could be confident that their needs would be met by a competent team of staff and that the careful selection of new staff would protect their welfare. EVIDENCE: Training courses in first aid, abuse awareness, fire safety and health and safety had been booked during March, April and May 2006. Residents were also invited to attend the training sessions on abuse awareness and fire safety. The home had not recruited any new staff since the previous inspection. Robust procedures for the selection and recruitment of staff were in place. Throughout the inspection staff were observed to interact well with residents and residents confirmed that staff treated them with respect. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 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, 39 and 43 The absence of a quality assurance monitoring system denies residents the opportunity to contribute their views towards self-monitoring, review and development of the home. EVIDENCE: Since the previous inspection the manager had enrolled on a course to study for the NVQ level 4 in Management. The home did not have a formal quality assurance programme. This was discussed with the manager to explore ways in which this could be achieved. The manager proposed to consult residents on what their understanding of a home was. From this a questionnaire would be developed to balance residents’ perceptions of a home against their actual experience of living at Bradmere. This will be assessed at the next inspection. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 17 The manager must also give consideration to how the views of visiting health and social care professionals and residents relatives will be surveyed. The home was displaying a current certificate of public liability insurance. Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X 1 X X X 3 Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 19 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 YA6 Regulation 15 Requirement Care plans must be subject to regular review. Previous timescale of 22/11/05 not met. The registered person must implement a safe system for the receipt, recording and administration of medication. The registered manager must achieve qualifications in NVQ level 4 in care and management. Timescale for action 07/05/06 2. YA20 13 (2) 14/04/06 3. YA37 9 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bradmere DS0000008343.V280797.R01.S.doc Version 5.1 Page 20 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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