Inspection on 12/01/06 for Bradstowe Lodge

This inspection was carried out on 12th January 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

Bradstowe Lodge 19/09/07

Bradstowe Lodge 12/07/06

Bradstowe Lodge 22/10/04

Bradstowe Lodge 28/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Bradstowe Lodge Bradstowe Lodge 22 Victoria Parade Broadstairs Kent CT10 1QL Lead Inspector Sandra Crosby Unannounced Inspection 12th January 2006 10:30 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 Bradstowe Lodge DS0000023329.V270307.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. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bradstowe Lodge Address Bradstowe Lodge 22 Victoria Parade Broadstairs Kent CT10 1QL 01843 861962 01843 604672 enquiriesradstowelodge.org.uk 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) Kent Old People`s Housing Society Limited Mrs Julie Martin Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Bradstowe Lodge is a large older style property, which has twenty-one single bedrooms. Every room has a call bell and TV point. There is a shaft lift in the home. The home caters for men and women over the age of 65 years, and is located opposite Broadstairs seafront, and within walking distance to the centre of Broadstairs town therefore close to all amenities. There is a small paved patio area to the rear of the premises, together with a paved area to the front of the premises. Both areas are maintained for the use of service users. On the road parking is limited to one hour around the vicinity of the home. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place on Thursday 12 January between 10.30 and 13.30. Since the announced inspection visit carried out on the 07 and 08 June 2005 the home has appointed a new manager who commenced employment at the home in October 2005. A short visit was made to the home on 31 October 2005 to meet the new Manager and to discuss issues of concern that had been raised. Action has been taken to address these issues. The focus of the inspection visit was to check on compliance with the requirements made in the announced inspection report dated 07 June 2005. Due to issues raised and discussed, and the time spent looking at documentation the whole of the inspection visit time was spent mainly with the newly appointed Manager. What the service does well: What has improved since the last inspection? A person/persons have been employed to cover cooking in the kitchen over the teatime period seven days a week. The external to internal wheelchair access has now been completed. Shower Room has been completed. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 6 Soap dispensers and paper towels containers have now been fitted in all bedrooms and appropriate areas. Action has been taken in relation to the safe storage and disposal of clinical waste. Duty managers uniforms have been changed, in order to ensure that these members of staff are not considered in anyway by the general public to be nurses. A new carpet is to be laid to one of the bedrooms this week. 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. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 7 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 Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 8 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): 1,3,6 The homes Statement of Purpose and Service User Guide provide Service Users and prospective Service Users with the information they need to make a decision about moving into the home. Service Users move into the home knowing that their needs can be met and that their independence will be maximised and promoted. It is not the general policy of the home to admit Service Users on a short-term basis, and this standard was judged as not applicable at this inspection visit. EVIDENCE: Standards 1 and 3 were judged as standard met and Standard 6 was judged as not applicable at the announced inspection visit dated 07 June 2005. These standards were not inspected at this inspection visit. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 9 The Statement of Purpose and Service User Guide were seen at the announced inspection visit dated 07 June 2005, and the Responsible Person agreed to review and update the documents. These documents were not inspected at this inspection visit. Completed pre-assessment documentation was seen at the announced inspection visit dated 07 June 2005, together with a completed KCC care management assessment for a recently admitted Service User. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 10 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): 7,8,9,10 The care planning system meets the requirements of the minimum standards and regulations, however cross-referencing and continuity of information needs to be maintained. The health needs of Service Users in the main are met, and in the case of one Service User at the time of the inspection visit was not met, and important information is not always appropriately recorded. The systems for medication administration are mainly good with clear and comprehensive arrangements being in place to ensure Service Users medication needs are met. Personal care is offered in a way to protect Service Users privacy and dignity. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 11 EVIDENCE: Standards 9 and 10 were judged as standard met and Standards 7 and 8 were nearly met at the announced inspection visit dated 07 June 2005. At this inspection visit Standards 7 and 8 were judged as not met, and Standard 9 was judged as nearly met. Three Service User Plans were examined, and discussion took place about the records seen. It was seen that cross-referencing was not always in evidence and the continuity of record keeping was not always followed through. It was also seen that records were not updated when changes had taken place for example removal of a catheter. In relation to the information on skin integrity records, two conflicting statements were seen in different sections of the Service User Plan dated the same date, one statement indicating the area was improving, and the other statement indicating that there was no improvement. There was also discussion in relation to an incident where a member of senior staff had agreed to undertake a daily blood pressure reading requested by a visiting GP. The Inspector discussed that homes staff should not agree to undertake any nursing procedures unless they have had training and provide written evidence stating that they are competent to do so. It was then discussed that the request of the GP had not been recorded at the time and not passed onto the next shift, consequently no action was taken in relation to this for a number of days. The Manager once aware of the situation has taken appropriate action to resolve this issue. Medication records were seen and indicated that they were mainly appropriately signed and up to date. During discussion it was stated by the Manager that she had found that medications other than the ones stored in the locked medication cabinet were being stored in an unlocked area of the home, and that this practice had now been stopped. The Manager also reported that the provider of medications to the home is to be changed in the near future. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 12 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): 12,13,14,15 Service Users spoken with confirmed they were happy with the lifestyle they had living at the home. Service Users are encouraged to maintain contact with family and friends. It was found from discussions with staff that Service Users may not have been able to exercise choice and control over their lives, in relation to certain routines within the home. The meals in the home are good offering both choice and variety and catering for special diets. EVIDENCE: Standard 15 was judged as standard exceeded, Standard 13 was standard met, and Standards 12 and 14 were nearly met at the announced inspection visit dated 07 June 2005. These standards were not inspected at this inspection visit. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 13 Service Users at the announced inspection visit dated 07 June 2005, talked about playing bingo, and taking part in armchair exercises. One Service User said that she had been out with her family that morning. Following the announced inspection visit action has been taken to provide more flexibility in relation to the Service Users being able to go to bed and get up when they wished. A number of people living in the home were spoken to during the announced inspection visit dated 07 June 2005 and everyone who commented on the food said how good it is. Food records were seen at that visit, and the meals provided on the two inspection days, was well presented and looked appetising. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 14 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): 16,18 The home has a satisfactory complaints system with some evidence that Service Users feel that their views are listened to and acted on. Policies and Procedures are in place to safeguard Service Users from abuse. EVIDENCE: Standards 16 and 18 were judged as standard met at the announced inspection visit dated 07 June 2005. These standards were not inspected at this inspection visit. Action has been taken by the Manager to resolve issues of concern raised in October of 2005. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 15 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): 19,26 The standard of the environment within the home is average and the Responsible Person has a good understanding of the areas in which the home needs to improve. Currently Service Users bedrooms suit their needs and lifestyles. The home was clean, pleasant and hygienic at the time of the inspection visits. EVIDENCE: Standards 19 and 26 were judged as standard met at the announced inspection visit dated 07 June 2005. These standards were not inspected at this inspection visit. The Manager reported that the external to internal wheelchair access had been completed and the Inspector was able to view this area. Soap dispensers and paper towels have been provided in all bedrooms and other appropriate areas. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 16 Action has been taken to ensure that clinical waste is stored and disposed of appropriately. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 17 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): 27,29,30 From discussion with the Manager it is indicated that currently Service Users needs have been met at all times by the numbers and skill of staff. Service Users are protected by the homes thorough recruitment procedures, and staff training is ongoing. EVIDENCE: Standards 29 and 30 were judged as standard met, and Standard 27 was judged as standard nearly met at the announced inspection visit dated 07 June 2005. Although these standards were not inspected at this inspection visit, it is indicated that currently there are sufficient staff on duty at all times to meet the needs of the current group of Service Users. The Manager also reported, that the teatime period is now covered by a Kitchen Assistant seven days a week. Four staff files were seen at the announced inspection visit dated 07 June 2005, and contained all necessary documentation. Evidence was seen at the announced inspection visit dated 07 June 2005, that shows that training is ongoing at the home. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 18 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): 31,34,35,36,38 Service Users are now beginning to benefit from a better run home since the new Manager was appointed, and on the whole the health, safety and welfare of service users and staff are mainly promoted and protected. Service Users are safeguarded by the accounting and financial procedures of the home. Member of staff are appropriately supervised, and the health, safety and welfare of Service Users and staff are promoted and protected. EVIDENCE: Standards 34,35,36 and 38 were judged as standard met at the announced inspection visit dated 07 June 2005. These standards were not inspected at this inspection visit. Standard 31 was judged as standard met at this inspection visit. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 19 The Manager is experienced in running a home, and is working towards creating an open, positive and inclusive atmosphere. The records of Service Users personal allowance monies were seen at the announced inspection visit dated 07 June 2005, and a sound system of recording is in place. Regular supervision is undertaken with written records kept. The fire log book was seen at the announced inspection visit dated 07 June 2005, and indicated that all regular monitoring checks are undertaken, together with regular fire drills taking place. The accident book records were also viewed. The homes insurance certificate was seen on display. Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 20 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 21 14 15 2 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 31 32 33 34 35 36 37 38 3 X X 3 3 3 X 3 Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 Timescale for action Maintain continuity and cross 12/01/06 referencing within the records of the Service User Plans – ensure that all necessary entries are recorded – Previous timescale 08/06/05 The registered person promotes 12/01/06 and maintains service users’ health and ensures access to health care services to meet assessed needs The registered person ensures 12/01/06 that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework Requirement 2 OP8 12 3 OP9 13 Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 23 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 Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Bradstowe Lodge DS0000023329.V270307.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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