Inspection on 16/06/08 for Brickbridge House

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Brickbridge House 98 Brickbridge Lane Wombourne Staffordshire WV5 0AQ Lead Inspector Mandy Brassington Unannounced Inspection 16th June 2008 11:30 Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 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 Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brickbridge House Address 98 Brickbridge Lane Wombourne Staffordshire WV5 0AQ 01902 892619 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) Positive Living Ltd Paul Anthony Ruby-Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) the service users of the following gender: Either Whose Primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 6 The maximum number of service users to be accommodated is 6. Date of last inspection New Service Brief Description of the Service: Brickbridge is a modern house on the outskirts of Wombourne near Wolverhampton. The home was registered as a new service in January 2008 to provide accommodation to six people with a learning disability. The home comprises of six individual bedrooms, four bedrooms are on the ground floor, three of which are suitable for people with a physical disability; all bedrooms have a toilet or full en-suite facilities. There is a bathroom, separate toilet, kitchen, dining room and lounge on the ground floor and two bedrooms and an office and sleep in room on the first floor. To the front of the home there is a grassed area and to the rear there is a patio. There is a large double garage, which also accommodates the laundry facilities. The home opened on 31 March 2008, and at the time of the visit the home had been operating for nine weeks. There were three people living in the home supported by a team of staff. People were able to choose how to spend their time, and since opening had been sharing ideas and planning events for activities. The Service User Guide did not reflect information relating to the fees in the home as required. The reader may wish to approach the care provider for up to date details of the fees payable. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use the service experience adequate quality outcomes. This visit was an unannounced key inspection and therefore covered the core standards. This was the first inspection of the service, which was registered in January 2008. The inspection took place over 6.5 hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for us. There were questionnaires sent to people who use the service, professionals and staff members. One completed survey from a person who used the service and one survey from a Health Care Professional was received. On the day of the inspection, the home was accommodating three people. We, the commission examined records, carried out indirect observation of three people who used the service, and four staff on duty. Three care plans and three staff records were examined and observation of daily events took place. A tour of the home was undertaken. Inspection of the storage system and medication procedures was inspected. What the service does well: The home is a large house with modern facilities and large rooms. People have spacious communal areas where they can choose to spend their time, or can spend time alone in their bedroom. Each bedroom contains personal equipment, photographs and pictures. The home has only been open for nine weeks and people are developing relationships with other individuals in the home and staff. Staff have been working individually with people to develop a support plan which has personal Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 6 information about people’s life, where they have lived and important events. People have shared information with staff about how they want to be supported, what they are like when they are happy, sad or angry and what they may say or do. People will be able to add or change information in the plan as information changes. In the home, individuals are supported to join in all household activities. This includes cooking and cleaning, planning meals and preparing the table. Individuals decide what they want to eat at each meal time. Everybody eats together including staff, and meal times are a social event. Individuals are able to choose how to spend their days. This can be listening to music, watching television, playing games or art activities. Staff are listening to what people want in their new home and looking within the local community at how they can help people join in with their chosen activities. Staff at the home support people sensitively with personal care. Everybody is able to wear smart clean clothes and express himself or herself in how they look. Staff are supportive of people developing personal relationships and keeping the relationships with family and close friends. What has improved since the last inspection? What they could do better: People in the home must be kept safe from fire and the fire equipment must be maintained at all times. Where a problem has been identified, it must be addressed promptly. The home must have a safe evacuation plan, and this must be continuously reviewed to ensure people can safely leave the building at all times. During the induction period and before staff have received their induction training, staff need to be supported and supervised. This includes how to Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 7 safely administer medication and how to manage any errors or admissions. All staff are to receive this training and the manager is currently assessing people’s ability to reduce any risk. People living in the home have complex needs and sometimes staff work alone. The home needs to assess how people are supported to ensure that individuals and staff are kept safe and not placed at risk. 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. The summary of this inspection report can be made available in other formats on request. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 8 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 Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions only take place after a comprehensive assessment has been completed, so the home can make a decision about how it is able to support people. Individuals are able to spend time in the home and visit on many occasions before deciding whether they would like to move in. EVIDENCE: The home was registered in January 2008, although the home began to provide accommodation for people on 31 March 2008, nine weeks prior to our first visit. Two people had moved from another home, which had closed, and a number of staff had been employed by Positive Living, therefore providing continuity of care. People had a copy of the Statement of Purpose and Service User Guide, which had been developed with pictorial support. The Guide included information about the service, what people could expect and the complaints procedure. The Guide did not include information about the fees and people did not have a copy of their contract. Discussion with the Provider revealed that agreed contracts with the placing authority were kept at the organisation’s Head Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 10 Office. It is required that each person has a suitable contract detailing the terms and conditions of occupancy and the fee level, which is also to be included within the Service User Guide. Individuals were able to visit the home prior deciding whether to move in and were supported to choose a room to meet their needs. For some people, family members had been included in the introduction to the home. We examined three personal files, which demonstrated that each person had a community care assessment and one person had information from the Discharge Team, including how to support individual complex needs. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plan being developed is individual to the person and focuses on strengths and personal preferences. With support, people who use the service are completing their plan to ensure it reflects how they want to receive care. EVIDENCE: We examined the plans of care for all three people and found that a plan had been developed using information within the assessment. The care plan included information on support needed for personal and daily living tasks. Assessments of risk were completed for support including vulnerability, medication and complex behaviour. Some areas of the plan were generic and recorded staff protocols and did not record how the risk was to be managed in relation to medication, vulnerability and behaviour. The manager Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 12 demonstrated the new plans, which were being completed by the people using the service with support from a member of staff. The new plans are to replace the computer generated plans. The new person centred plans included information about the person, how they wanted to be supported with daily living skills and personal care. Information about how people communicated, important family and friends in their life, my life now and my life story, keeping safe, medication, things I do and don’t like and aspirations for the future was recorded. Information was very personal, of which examples included not liking bumpy surfaces, as the person used a wheelchair in the community, and dislike of flies and spiders. The record included details about where people had lived and events that had occurred in their life during that period. There was personal information such as their first date, where it took place and the name of the person. The plan included details about religion and how people wanted to be supported to attend their preferred place of worship, sexuality and supporting people to develop and promote their own sexuality, or to have close personal relationships. This in-depth, personal information will help the staff to support the people using the service with a better understanding of their individual personalities. One person has in depth information regarding management of complex behaviour. The records showed that there were several meetings and visits prior to the person moving into the home to ensure staff understood the complex needs of the person. Discussion with people who use the service revealed that staff had completed the plans individually, and one individual felt at ease when disclosing personal information. The person was aware that it was their plan to which they were able to have access. Within the AQAA the manager reported that the plans would be formally reviewed after six months although identified that as people were new to the service this review process would be continual. From observation, it was evident that staff supported people to make decisions throughout the day; observations included choice of activities, meals and refreshments and who should access to information. The manager confirmed verbally and within the AQAA, that people are empowered to take control over all areas of their lives and it is recognised that people may need to develop skills and confidence to take control. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 13 Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can make choices in all areas of their life and have opportunities to join in with social and recreational activities. Personal relationships are encouraged and people are can develop and maintain existing relationships. EVIDENCE: The home has only been operating for nine weeks and discussion with the manager and staff revealed that discussions have taken place with people about what they would like to do and places to go. The new person centred plans have recorded people’s preferences, and staff stated that they are investigating new activities. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 15 The manager reported within the AQAA that one person had expressed a desire to gain employment within the voluntary sector. The manager reported that the staff will be sourcing locally based voluntary sector organisations with a view to the person undertaking voluntary work of their choice. Discussion with one person confirmed that they are interested in gaining work experience. Discussion with staff and people who use the service demonstrated that they were aware of local facilities and since opening, had used the local shops, visited local pubs and one person has been walking with support along the local canal paths. Two people had started playing football within a local group and everybody has attended a social club with friends. Staff reported that people have expressed an interest to go to the cinema and starting to learn to swim. One person remarked ‘I get to go out a lot, especially shopping, but if you want to stay in, or have a lie down or rest, that’s fine.’ The advantages of living in a semi-rural location of the home was highlighted in one new plan of care. One person stated they, ‘enjoyed being able to watch local wildlife and to see the countryside each day’. The home had many holiday brochures for people to look at, and people said they are thinking about where they would like to go on holiday. Disneyland Paris and Rhyl are being discussed, and one person spoke enthusiastically about wanting to have the experience of flying and hoping to go to America the following year. Meals are chosen on a daily basis, staff were observed providing people with a choice of foods. Throughout the visit, people were able to have refreshments and snacks. One person was supported to make their own drink and staff were aware of the risks for that person and how the individual’s health could impact on the risk. Within the AQAA the manager reported that people are able to continue to have active family and friend involvement. Visiting is undertaken at a time that is suitable for both all persons and visiting can take place in the privacy of service users rooms if that is what is wanted. Upon arrival at the home two family members visited one person. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to access healthcare services, and are encouraged to have regular appointments and visit local health care services, to ensure their wellbeing. Robust medication practices need to be developed to ensure people receive their medication to keep well. EVIDENCE: Staff have been completing a Health Action Plan with people who use the service, which includes information about any health need, information on continence, skin care, weight, oral hygiene, epilepsy, and men’s and women’s specific health issues. Details of all action to be taken to ensure any need is met are recorded. One plan we examined contained information about epilepsy, including the type of epilepsy and how the seizure may be observed. A record of all seizures Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 17 had been recorded, and in conjunction with health care professionals, the medication had been reviewed. Medication was now administered earlier in the day, which had reduced the number of seizures. Upon arrival at the home one person was visiting a dentist as a new patient, and during the afternoon, one person attended the hospital for an appointment with a neurologist. The manager reported that people are able to receive support to attend all health appointments where required. Al people are registered with a General Practitioner (GP), and within the AQAA the manager reported that where a new GP is required then personal preference is taken into account. One person has requested a doctor of the same gender to enable the person to feel at ease to talk about personal issues. One person requires support with mobility. The plan of care contained and assessment of needs and identified equipment that had been provided in the home. The person reported they were able to remain independent due to the provision of the equipment. Discussion with staff revealed people were aware of how to support people with different faiths, and would enable people to develop personal relationships with a companion of their choice, irrespective of gender. People using the service were able to dress in a style of their choosing. Everybody was clean and well presented. One person reported ‘I love going shopping and have lots of clothes.’ The Monitored Dosage System was used for two people and arrangements had been made for all people to receive their medicines in blister packs. Plans of care recorded the name and type of each medicine, including possible side effects. This had been recorded in a clear and easy to read format. During the weekend prior to the visit the Medication Administration Record had been completed for one person, although medicines were still within the blister pack. A note had been recorded in the communication regarding the error, although the on call manager and advice from health professionals had not been sought. Staff reported they were to attend training for safe administration of medication as part of their induction. The manager reported that staff were assessed administering medication and no other errors had been recorded since the home had opened. It is required that staff receive suitable training and support to ensure all medication is administered safely including understanding protocols for how to respond to medication errors. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure that is clearly written and is available with picture symbols, and everyone living at the home has a copy. The staff understand the procedures for Safeguarding Adults and have a good knowledge of how to respond to an alert to protect people. EVIDENCE: The Complaints procedure is written with the support of pictorial symbols and a copy was available in the Service User Guide. Discussion with one person demonstrated that they would have no hesitation in raising any concern or complaint. The person commented that they felt safe in home and knew they were able to receive support from an advocate. There have been no complaints received by us, since the home opened in January 2008. Training for safeguarding people has been planned for staff as part of their induction; staff reported they had completed this training during their previous employment. Discussion with staff revealed people were knowledgeable about forms of abuse and how to respond to any alert. Staff reported they were made aware of the Whistle blowing procedure, which was looked at during the first days of employment. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are encouraged to see the home as their own and can personalise their bedroom and communal areas and the home is a pleasant place to live. Fire precautions in the home need to be assessed to ensure people are able to keep safe in the event of a fire. EVIDENCE: Brickbridge is a modern Bungalow on the outskirts of Wombourne near Wolverhampton. The home was registered as a new service in January 2008 to provide accommodation to six people with a learning disability. The home comprises of six individual bedrooms, four bedrooms are on the ground floor, three of which are suitable for people with a physical disability; all bedrooms have a toilet or full en-suite facilities. There is a bathroom, Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 20 separate toilet, kitchen, dining room and lounge on the ground floor and two bedrooms and an office and sleep in room on the first floor. To the front of the home there is a grassed area and to the rear there is a patio. There is a large double garage, which also accommodates the laundry facilities. As part of the assessment process, specialist equipment required for people to retain their independence and to promote health was identified and included in the home. People have been able to bring personal furniture and possessions with them and keep them in their room or within the communal areas. People are able to have access to all parts of the home and garden. In the early evening people were able to have a drink and food on the patio due to the pleasant weather. On the day of the visit, staff were unable to open the front door due to a fault; the front door is a fire exit. This had been reported in May and although contractors had assessed the door on two occasions, the door had not been fixed. On the ground floor the windows were locked and staff did not have a key to the French doors in the lounge. On the first floor the office fire door closure was broken. The manager reported that the fire risk assessment had not been reviewed to ensure people were able to safely evacuate from the house. It is required that the registered person consults with the fire department and demonstrates to us that the home has suitable facilities to evacuate all persons and keep people safe. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a good recruitment procedure to protect people living in the home. People need to be supported in line with identified needs to ensure they are safe. EVIDENCE: The home operates two day shifts and a night shift. During the day, two staff are on duty on each shift and the manager works flexibly across the shifts. At night time, one member of staff is awake and one person sleeps in. The manager confirmed that this was the usual pattern of shifts. The registered person stated the staffing would be reviewed as people moved into the home; the current staffing provided was based on three people living in the home. Three staff records were examined, which demonstrated that the organisation has robust recruitment practices. All records included a photograph, an application form, two written references, a Protection of Vulnerable Adults (PoVA first) check and a Criminal Records Bureau Check (CRB). Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 22 Staff receive a three day induction to the home, whereby staff are able to become familiar with plans of care and policies and procedures. The induction period for training is six months, and the manager is organising training for safe administration of medication, health and safety, moving and handling and management and support of people with complex behaviour. Records demonstrated that one person has received training for complex behaviour, risk assessment and adult abuse awareness. Staff records recorded where people have received training in previous employments. The manager must ensure that staff are suitably supported during the six month induction period to ensure the safety of service users and staff. On the day of the visit, the manager and a member of staff supported one person to the hospital. One person worked alone with two people who use the service. One person was unsupported for twenty minutes as the other person required personal support. We needed to support the other person who wanted a drink to be made. It is a concern that people in the home have been identified as having complex needs and staff were observed working alone. The staff member felt confident to manage any situation and confirmed that if there was any concern, additional staff would be obtained or visits cancelled. It is required that the service provider carry out an assessment of risk in relation to support needs, and demonstrate how people’s needs are met and people are safe with the current staffing levels. Consideration is also to be given to the support, supervision and training required for staff. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has an understanding of the principles and focus of the home and is supporting people who use the service and staff to develop an individual service. EVIDENCE: Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 24 It is evident from observation and discussion with staff, that the manager is enthusiastic and committed to developing a good service. The manager has introduced person-centred care planning into the home to ensure people are able to record how they want to be supported. The manager is experienced and open and transparent in all areas of managing the home. Staff commented they felt valued and part of a supportive team and would have no hesitation approaching the manager. The manager is arranging for staff to complete all mandatory training as part of their induction and this will be assessed within our next visit. The manager has begun to work with the team of staff to develop person centred plans, which reflect how people want to be supported in their new home. Prior to the Inspection, the manager completed an Annual Quality Assurance Audit (AQAA) for us. The AQAA contained clear, relevant information that was supported by a wide range of evidence. The manager reported that as the home had only been open for two months at the point of completing the AQAA there was limited information to record. The manager must ensure that the safety of all persons in the home by addressing current fire precautions and systems to safely evacuate all persons. This is needed to ensure people are safe and for the fire risk assessment to take into account individual’s dependency and needs was discussed with the manager, who agreed that further consultation would take place with a suitable and qualified person. All environmental work and testing was completed as part of the registration process and checked by us prior to the registration the home. This will be reviewed on the next visit to ensure the property is suitably maintained. Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 5 Requirement Timescale for action 16/08/08 2 YA20 13 (2) 3 YA24 13 (4) The Service User Guide must include details of the fees and each person needs a suitable contract available with these fees included, to ensure they are aware of what is paid, any contribution and how this relates to the terms and conditions of occupancy. When medication is not 16/07/08 administered to people it must be clearly recorded, to ensure that people receive the correct levels of medication. Any omissions or errors need to be recorded and advice obtained from a health professional. Staff need to receive suitable support, training and guidance to ensure all medication is administered as prescribed and follow safe practices for any errors. Suitable Fire systems and fire 16/07/08 evacuation procedures must be in place to ensure all persons can be safely evacuated. Current arrangements need to be reviewed with the fire officer and the registered person must DS0000071010.V366621.R01.S.doc Version 5.2 Brickbridge House Page 27 4 YA33 24 (1)(2) demonstrate that people in the home are protected from the risk of fire and can be assisted to evacuate safely from the home. Where it is identified within the 06/08/08 plan of care that people have complex needs and require support, suitable staffing is required at all times. An assessment of risk is to be carried out in relation to the current staffing provided to ensure that people and staff are safe in the home and suitable support is always provided. A copy of this assessment is to be sent to us. 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 YA35 Good Practice Recommendations Staff should be suitably supported during the induction period to ensure they have the experience and knowledge required whilst awaiting specific training Brickbridge House DS0000071010.V366621.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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