Inspection on 11/07/06 for Bridge House

This inspection was carried out on 11th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Bridge House 25/02/09

Bridge House 03/09/08

Bridge House 09/10/07

Bridge House 28/11/05

Bridge House 04/07/05

Bridge House 13/10/04

Bridge House 05/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bridge House Topping Fold Road Bury Lancs BL9 7NQ Lead Inspector Lucy Burgess Unannounced Inspection 11th July 2006 09:30 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 Bridge House DS0000008412.V297650.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 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. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridge House Address Topping Fold Road Bury Lancs BL9 7NQ 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) 0161 764 1736 0161 797 5045 European Care (UK) Limited Mrs Pamela Elizabeth Rooney Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. 28th November 2005 Date of last inspection Brief Description of the Service: Bridge House is owned by European Care (UK) Ltd. The home is registered to provide care and accommodation for up to 34 older people. The range of fees are from £341 to £4ss, this is dependent of funding arrangements and room preferences i.e. larger rooms with en-suite facilities. Bridge House is an attractive detached house situated in a residential area approximately 1 mile from Bury. The majority of bedrooms are on the ground floor. There are twenty-eight single bedrooms and three doubles. Twenty of the single rooms are en suite. There are well-maintained spacious gardens, which are easily accessible to the residents and visitors. There is also ample space for car parking. In addition to care staff, the home also employs cooks, kitchen assistants, domestic staff, a maintenance worker and an administrator. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home. The day was spent looking at records and information about residents, staff and the home. The inspector also spent time looking around the home, speaking with residents, family members, staff and the Registered Manager. As part of the inspection the Registered Manager was asked to complete a preinspection questionnaire. This was provided and additional feedback was requested from professionals who visit the home. Eight responses were received, this included 2 from social workers and 6 from visiting GP’s. Comments have been included within the report. All the key standards were looked at during this inspection visits. What the service does well: What has improved since the last inspection? All but one of the requirements and recommendations made at the last inspection were addressed ensuring that the residents are cared for safely. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 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. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 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 Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 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): 3 and 6 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. The completion of detailed assessment information enables both the home, prospective residents and their families to make an informed decision about the suitability of the home and whether needs can be met. EVIDENCE: The file for one of the new residents was examined. This was to look at the assessment carried out prior to admission. Information seen included a preadmission assessment form covering areas in relation to the persons’ personal details, NOK, GP, SW and medication, diet, weight, medical history. Other areas covered included personal care and physical well-being, communication, mobility, falls, continence, mental states, social, personal safety and risks and contact with others. The assessment however had not been dated and signed by all relevant parties. A second form was on file. This was the admissions assessment form. This provided more information in relation to communication, mood, behaviours, Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 9 eating and drinking, personal care, mobilising, work and play, routines including rising and retiring and cultural needs. This assessment had been signed and dated by the senior carer, who had completed the form. Discussion held with manager with regards to the admission process. The inspector was advised that if a residents was funded by the local authority then a community care assessment is requested. Arrangements would then be made for the manager along with a carer to go out and do their own assessment to determine if the placement would be suitable. In relation to those prospective residents who are privately funding their placement, the manager stated that the statement of purpose and service users guide/homes brochure would be sent out. An assessment would also be undertaken either at their home or at Bridge House. All prospective residents are encouraged to visit the home and are welcome to have lunch or short stays, before a final decision is made. A joint decision would then be made. Those residents wanting the larger rooms with en-suites are advised that they will be responsible for the top-up charge. All new placements are initially reviewed after 6 weeks to determine if the placement is meeting the identified needs. One family member spoken with explained that she had other family members whilst looking for accommodation for their relative had visited the home without prior arrangement and were ‘made to feel very welcome’. She stated that they ‘were impressed with the environment and the helpful staff’. Standard 6 does not apply, as the home does not provide Intermediate Care Services. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 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 and 10 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Whilst residents’ care needs and assessments are in place, information needs to be developed and monitored so that records fully reflect the changing needs of residents ensuring their safety and well-being is addressed. A safe system of administering and recording of medication was in place. EVIDENCE: Several residents were identified as part of the case tracking process. Three individuals were identified. Files contained a number of documents including admissions information, social care assessments, dependency charts and risk assessments. Additional records were made of professional visits, weight and daily diaries. On examination of the files several areas had not been completed in full, had not been reviewed monthly or signed to evidence service users and/or their representatives involvement. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 11 Through discussion with the manager it was noted that she is trying to establish family/representative review meetings, involving them in the development of care plans and risk assessments. This will also provide the manager with an opportunity to ensure that documents are signed by all relevant parties evidencing their agreement with what has been documented. Areas of development were found on each of the files. On the first file it was found that the water-low/pressure care assessment had been completed however did not state clearly how the score had been meet or what intervention was being made. The nutritional assessments had some discrepancies between May and June. May had been scored as 3 stating underweight whilst in June it was scored as 4 obese. Those staff completing the assessment must clearly show how this has been scored so that the assessment fully reflects the residents’ needs. The continence assessments had not been updated since February 2005. The initial wound assessment did not have the service users name. Information regarding blood tests did not provide any follow up details with regards to the results or reason for the test. Further correspondence was held on file including a letter from the hospital in relation to the resident having epilepsy, however this had not been identified on the care plan. The second file showed that the resident had moved into the home following the closure of another care. Records held in relation to care needs were passed from the previous home to Bridge House, including previous local authority reviews. Within the homes social care assessment it was stated that the resident does not speak English and does not have any cultural needs. It also states that the resident does not follow their religion/culture as she is ’non coherent and cannot express herself’. The dependency chart identified that the resident was socially disruptive, extreme confusion, suffered depression but could understand simple instruction. It was questioned whether some of the behaviour was related to the resident no longer being able to see or fully verbally communication with the staff and residents therefore causing some frustration and anxiety. This has been referred further within the report. The nutritional assessment identified that the resident required support with meals however had not been weighed for 3 months. This needs to be monitored. Diary notes state that the resident was also trying to move around on her own, was having outbursts of aggression and hitting out. The care plan should demonstrate what action is being taken to address these issues. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 12 Both care plans had not been reviewed, updated and signed. In the third file it was found that the dependency chart issues had been identified with regards to excessive alcohol intake. This is an issues related to the family which the manager is trying to address. It was unclear how the score on the water-low assessment had been met. The nutritional assessment showed no score given for neurological/mental health condition of the resident therefore not providing an accurate score. As already stated each of the residents also have a daily diary where information is recorded by staff on each shift and outlines what they have done during the day or if any issues or concerns. It was discussed with the manager about the admissions assessment being rewritten and re-dated. This document refers to information, which was relevant at the time of admissions therefore does not need to be repeated. The care plans and risk assessments are the main documents which should evidence the change in need and how this is being managed, these documents must be reviewed and up dated on a monthly basis. Observations of residents found individuals very settled and relaxed. Residents were appropriately dressed, clean and tidy and sat with other residents in the communal lounges. Interactions with staff were warm and friendly. Staff have a good understanding of individual needs etc. Relatives spoke very highly about the service and the staff support. Comments included, ‘the home have been wonderful with mum’, ‘they’re marvellous staff’, ‘they keep in contact and let me know about everything’ and ‘they take very good care of her’. Feedback surveys were also received from 2 social workers and 6 visiting GP’s. Comments included ‘service users and their families have been very pleased with the care and support’ and ‘very satisfied with the care’. Each of the health and social care professionals answered ‘Yes’ to being able to see the residents in private and that staff demonstrate a clear understanding of the care needs of residents. In relation to medication the home has 3 trolleys, 1 for morning and lunchtime meds, 1 for evening and night-time and the third for additional stocks. The trolley in use is held securely within the dining room, then swapped with other when needed. These are held securely with the a separate locked room. Controlled drugs are held for 2 residents. Suitable lockable storage available, drug register. Administration was signed by two members of staff. Sample signatures are also held on file for the 7 staff that have been trained to administer medication. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 13 Stocks appeared to be managed well with regular returns made when required. Records made of all items brought into the home and returned to the supplying pharmacy. Medication was seen to be administered in medication pots, mars sheets were signed on administration and sheets were completed in full. Photos of residents where held with the relevant sheets. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements regarding activities are in place offering choice and stimulation however this area could be explore further particularly with those residents who do not have English as a first language. The dietary needs of the residents were also catered offering choice. EVIDENCE: Residents continue to enjoy regular contact with family and friends. Residents were seen to come and go with family. Daily records evidence that these activities take place. As previously identified family members have expressed that they are always made welcome when visiting the home. In relation to activities the home has planned a garden party planned for the end of July. Invites have been extended to family and friends as well as members of the local community centre, where some of the residents have been involved in judging an art competition as well as helping with tabletop events. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 15 Communion and visits from the local clergy also take place each week and the hairdresser visits every Tuesday. Other activities are organised by the staff and include bingo, outings, sing-alongs. The manager has also done a reminiscence course. Residents were said to enjoy watching the television, have birthday parties and newspapers and magazines are delivered to the home. A lady from the local library also visits twice a month to do a reminiscence session. The manager explained that there is money in the budget for an activity worker for approximately 16 to 20 hours per week, however has not had any real success in recruiting anyone. This is to be followed up. In relation to autonomy and choice (as referred to in previous standards) the manager has been asked to explore this area with particular reference to the 3 residents who are Polish/Ukrainian. Although staff have now developed a way in which to communicate with the residents it is felt that this could be explored further and that with the support of their advocates and possible recruitment of Polish (regular intake of oversees workers are employed by European Care) this would enable communication and integration to occur more easily. Allowing the residents to make more decisions for themselves. The home has a spacious dining room, which enable easy movement particularly for those who require assistance with mobilising. Tables were nicely set with clothes, flowers and cruets. The nutritional needs and weights of residents are recorded. Lunch provided was steak and onions with potatoes and vegetables followed by homemade crumble and custard. Tea was homemade soup, sandwiches and homemade buns. Where necessary build up drinks are also provided. Those residents requiring assistance are support by the staff. The inspector looked at the stocks available. The home receives regular deliveries of dried, fresh and frozen goods. Additional fridge and freezer space are available in the basement and garage. It was noted however that the kitchen looked tired and in need of replacing, units were worn and broken. This has been detailed further within the report – under environment. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place in relation to the protection of service users as well as responding to their concerns however outstanding training is still required. EVIDENCE: Policies and procedures are in place covering these standards. Some of the staff have received training in Abuse in Care. The course content included current legislation, statistics, no secrets and POVA, types of abuse and recognising signs, good practice and what to do. Whilst a large number of staff have completed the course there are still some outstanding including the new staff. A further course needs to be arranged. Of the three staff training files seen only one evidenced that this training had been undertaken. A complaints procedure is available and provided to residents and their families. A recent issues was brought to the attention of the CSCI. This was forwarded to the manager for her to respond to the complainants. Action has been taken to address the matter and a meeting is to be held involving all necessary parties to clarify the matter. A copy of the response is then to be forwarded to the CSCI. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Bridge House provides pleasant accommodation. This would be further enhanced with some refurbishment and improvements needed within the home so that the residents and safe and comfortable. EVIDENCE: Bridge House is a private residence set in its own grounds. There is a long driveway with ample parking spaces. The home is well-maintained with attractive gardens. Work identified within the last report has been addressed. The home provides a number of communal area’s where residents are able to relax. The majority of bedrooms are on the ground floor. There are 28 single bedrooms and 3 double rooms, 20 of the single bedrooms also have the provision of an en-suite. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 18 The owners of the home, European Care are exploring the option of extending the property to accommodate up to 47 residents. All communal areas were looked at and some of the bedrooms. Carpets need replacing in rooms 1 and 2 and directly outside the rooms as this is looking very worn and marked. Communal areas were pleasant however had not been decorated for sometime. The manager is to forward the homes redecoration and refurbishment plan to the CSCI. Action also needs to be taken with regards to the kitchen area, the cupboards were worn or broken, tiles needed cleaning and re-grouting. The room would benefit from a complete refit making more suitable arrangements for the storage of items within easy reach of the kitchen staff, providing facilities of a reasonable standard. The home was clean, tidy and odour free. The home employs designated domestic and laundry staff to ensure that the cleanliness of the home is maintained. Sufficient supplies were available with regards to protective clothing. There is also a full-time maintenance man that deals with all general maintenance and repairs. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 19 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, 28, 29 and 30 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staffing levels and training are provided. Some improvements are need to staff recruitment files to ensure the safety and protection of the service users. EVIDENCE: On examination of the rota sufficient staff were in place to meet the needs of residents. Copies of rotas were taken for the week of the inspection. The home has 19 staff including the manager, deputy, seniors and carers. There are also 9 ancillary staff, which include 2 cooks, 3 kitchen assistants, 4 domestics and a maintenance man. There is also a full time administrator. Agency staff are not used by the home, any cover required is done by the existing staff team. Staff • • • • • • • • training and development has been provided. This has included: Infection control Health and safety Fire safety Food hygiene Dementia 1st aid Medication Adult abuse DS0000008412.V297650.R01.S.doc Version 5.2 Page 20 Bridge House Acknowledgements had been signed with regards to staff receiving a copy of the terms and conditions, staff handbook, whistle blowing policy and confidentiality policy. NVQ training has also been made available. Nine staff have already completed the course. Further arrangements are being made for the newest member of the team and some of the existing staff to enrol for the training in levels 2 and 3. The Manager is also completing the Level 4/Registered Managers Award. The home has now become part of the Bury Partnership Scheme, which provides opportunities for training. In relation to staff recruitment the file was examined for the newest member of the team Information held included an application form, CV, references, POVA check. The home is awaiting the return of the CRB. It was found that the three references on file had been addressed ‘to whom it may concern’ and not directly to the Manager, none of the references were from the last employer. Information was also noted that information did not include a completed medical questionnaire or a photograph. The home contract/terms and conditions are issues on completion of the probationary period. European Care Organisation, the owner of the home, employ overseas workers including individuals from Poland. It was discussed with the manager about posts being offered at Bridge House as this may provide opportunities for the residents to converse more with staff and perhaps encourage more inclusion. Discussion was held with the new staff member about the interview process and starting work at the home. During the visits the staff members was shadowing existing staff as well as being given information by the senior on duty. Some discussion had also been held with her about training opportunities. Comments made about the team included, they’re very friendly, very helpful and welcoming. Staff had not received copies of the GSCC code of practice booklet. The manager is to access additional copies and distribute them to each member of the team. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 21 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, 33, 35, 36 and 38 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. The home was being suitably managed at this inspection. With the development of effective quality monitoring systems this will enable the home to achieve its aim in providing a good quality service for the residents. Adequate arrangements continue to be in place to safeguard service user finances Suitable arrangements are in place ensuring the safety of residents and staff. EVIDENCE: The Manager is currently completing the NVQ level 4/Registered Managers Award with hopeful completion by December 2006. A copy of certificate has been requested on completion. The Manager has worker at the home since 1995 undertaking several roles before becoming the Registered Manager in March 2006. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 22 She has a good understanding of the needs of older people and is aware of her responsibilities as manager. She undertake training both within the home and on more of a strategic level with other managers across the organisation. In relation to quality assurance and monitoring the Manager has already stated has periodic evening surgeries where relatives/representatives can meet with her to discuss anything. Customer satisfaction surveys are sent out biannually, these are currently being collated and feedback gathered. A copy of the final report has been requested. The home has recently achieved IiP. The organisation as a whole also recognises that improvement could be made in this area with key issues to include how service users are involved in shaping services. The organisation has also set out a three year business plan. The Manager was attending a conference the day following the visit to look at service development. In relation to residents’ finances, families are encouraged to maintain responsibility of the resident is not able. Only personal monies are held by the home. A random sample was checked. All records balanced with the money held. Receipts are also held for each transaction. Evidence of staff supervisions were seen. Information discussed includes work performance, targets and personal development and training. These were signed by both parties. The manager is aware that these have not been held as often as required. This has been due to her current workload however is aware that she needs to catch up. In relation to health and safety, as already stated the home employs a fulltime maintenance man who takes responsibility for the general repairs required within the home. He also carries out all in-house fire safety checks, temperature checks and pat testing. Safety certificates were seen on file for the fire equipment, bath hoists, portable appliance tester, electrics, gas supply, stair lift, ventilation and fire alarm and lighting 5/06. Recent training has also been undertaken by staff in areas of health and safety. Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 24 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 Requirement That the Managers ensures all residents care plans and risk assessments are completed in sufficient detail that clearly identifies how each resident’s needs in respect of their health and welfare are to be met as outlined within the report. Outstanding requirement – 31/01/06 That the Manager ensures a detailed risk management assessment is completed for those residents who are supported using bed rails. That the Manager encourages residents and their relatives/representatives to sign the care plans evidencing their satisfaction and involvement. That the Manager takes the necessary action to resolve the outstanding complaint. That the Manager ensures training in adult abuse/protection is completed by those staff yet to do so. This should also involve all ancillary staff. DS0000008412.V297650.R01.S.doc Timescale for action 30/09/06 2. OP7 15 30/09/06 3. OP7 15 30/09/06 4. 5. OP16 OP18 22 18 30/09/06 30/09/06 Bridge House Version 5.2 Page 25 6. 7. OP19 OP19 23 23 8. OP19 23 9. OP29 19 10. OP36 18 That the Manager forwards a copy of the home refurbishment plan to the CSCI. That the Manager makes the necessary arrangements to replace carpets in bedrooms 1 and 2 and that immediately outside of the rooms. That the Manager ensures that arrangements are made to replace the current kitchen units and bring the kitchen up to a reasonable standard. That the Manager ensures that staff recruitment files contain all relevant information as detailed within the report prior to staff commencing employment That the Manager ensures that all staff receive supervision on a bi-monthly basis and discussions are dated and signed by both parties. 30/09/06 30/10/06 31/12/06 30/09/06 30/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP14 Good Practice Recommendations The Manager must ensure that the pre-admission assessment is signed and dated by all relevant parties to evidence their involvement and date of completion. The Manager should consider the recruitment of Polish staff within the home as this may benefit the Polish/Ukrainian residents offering opportunities for interaction and more inclusion within the home. The Manager must ensure that all staff are issued with a copy of the GSCC code of practice booklet. That the Manager forwards a copy of her NVQ/RMA certificate to CSCI on completion of the course. That a copy of the report regarding feedback from the satisfaction surveys is forwarded to CSCI. DS0000008412.V297650.R01.S.doc Version 5.2 Page 26 3. 4. 5. OP29 OP31 OP33 Bridge House Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Bridge House DS0000008412.V297650.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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