Inspection on 08/01/07 for Bridge House

This inspection was carried out on 8th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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

Bridge House 04/12/08

Bridge House 15/02/06

Bridge House 08/09/05

Bridge House 14/03/05

Bridge House 22/09/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Bridge House 2 Bridgwater Road Taunton Somerset TA1 2DS Lead Inspector David Kidner Key Unannounced Inspection 8th January 2007 10:00 Bridge House DS0000039957.V319035.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 Bridge House DS0000039957.V319035.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. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridge House Address 2 Bridgwater Road Taunton Somerset TA1 2DS 01823 334797 01823 353691 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) Home First & Foremost Ltd Mr Gavin Guy Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2006 Brief Description of the Service: Bridge House is registered with the Commission for Social Care Inspection to support up to eleven people with a learning disability. It is a large detached property located within walking distance of Taunton town centre. Service user accommodation is provided over two floors. The home does not have a passenger lift. Service users bedrooms are arranged over two floors and have full en-suite facilities. There are two lounges, a large dining room and large domestic kitchen within the home. The garden, to the rear of the property is an attractive space made secure and accessible for service users. The Registered Manager is Gavin Guy and the Registered Provider is Voyage Ltd. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced Inspection took place over one day (8.25hrs). The Inspector met most service users and a large number of the care team. The Registered Manager was available throughout the inspection. As part of the inspection process the inspector viewed records in relation to care and support plans, health and safety, medicines, risk management, the management of behaviours and physical intervention, staff recruitment and viewed all areas of the home. The Inspector spoke to some service users in private and in communal areas. The Inspector would like to thank the service users for making the Inspector welcome in their home and for their contribution in the inspection process. The Registered Manager and the care team were very welcoming. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. As part of the inspection process the Inspector sent comment cards to all relatives. Six cards were returned. The comments received were very positive in relation to the care and support provided by Bridge House. All relatives were happy with the overall care provided and stated that they are kept informed of important matters that affect their relative. The Inspector sent comment cards to all care managers and healthcare professionals who have contact with the home. Seven were returned. All comments were positive about the overall care provided at the home. As a result of this inspection the home has four requirements and five recommendations. What the service does well: Bridge House is well managed and provides a homely environment that is very well presented and maintained. The service users appear settled, comfortable and well supported. The home is furnished and decorated to a good standard and has a comfortable and homely atmosphere. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 6 The Expert by experience commented, “ I was impressed with the size of the house, that there was a lot of space but also felt cosy and friendly. I liked seeing the pictures of the residents on the walls as this made it more homely” Care plans and risk assessments are detailed and reviewed on a regular basis. The Expert by experience spent a period of time talking to service users about activities and observing the activities that were happening. The Expert by experience said “I was at the home the residents were having a karaoke morning. I observed some of the residents taking part in this. I thought the staff interacted with the residents very well and motivated the residents to take part and took part themselves”. Other comments from service users to the Expert by experience were; “Sometimes I decide what to do”. Staff choose activities and I like all my activities”. I go out with staff and go to the shops” The Expert by experience asked about activities in the home and was told, “Sometimes I sweep the floor and wipe the tables. “I do painting”. One service user said that they sometimes shops for the house and also said “I make some decisions, my key worker asks me if I want to go shopping”. “Sometimes staff think of things, sometimes I do”. “There are enough staff working so I can do activities.” The home records the activities and opportunities that service users undertake. “I give the home 10 out of 10, the green flag. I felt the staff were caring with the residents and staff knew what the residents wanted which I could tell from the expression on the residents faces”. The home benefits from a positive staff team who support and encourage all service users in a kind and supportive way. Staff have skills in alternative methods of communication and the management of behaviours. Staff are offered a variety of training opportunities. What has improved since the last inspection? Bridge House has started to introduce service user meetings. This is very positive and should continue. The home has developed a more detailed recording system for activities in and out of the home. A washbasin and radiator guard in the dining room has been replaced. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Bridge House DS0000039957.V319035.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 Bridge House DS0000039957.V319035.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Key Standard 2 and Standards 3 and 4 were not assessed, as there have not been any new admissions to the home since 30.04.2002. EVIDENCE: The home has a detailed Statement of Purpose and Service User Guide. The Inspector requested that the home forward a copy of the updated Statement of Purpose and Service User Guide following the new appointment of Registered Manager. Fees vary according to assessed need. The current ranges of fees vary from £987 - £1792 per week. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 10 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 9 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has detailed care and support plans and individual risk assessments that are reviewed regularly. Service users are encouraged to make decisions. EVIDENCE: The Inspector viewed three care and support plans plans. All where detailed and comprehensive and had been reviewed in December 2006. The care plan files included a personal profile, records of health care and professional’s contact, behaviour management guidelines, summary of activities undertaken, contact with relatives and monthly summaries that are completed by the key worker. The Registered Manager stated that the home is reviewing the format in which the care and support plans are presented. The Inspector was shown a template Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 11 of the proposed document. It appears that the format for the proposed care and support plans are more person centred. Service users are encouraged to air their views as much as possible. The Registered Manager advised that the views of service users are sought on a day-to-day basis. At the time of the inspection the Expert by Experience observed service users being given choices in drinks and activities. The Expert by experience stated that when a service user was spoken to about decision making the reply was as follows: “I make some decisions, my key worker asks me if I want to go shopping. Sometimes staff think of things, sometimes I do”. The home also keeps day-to-day records of activities and opportunities that are provided with the outcomes. At the time of the inspection all service users needed support to manage their finances. No service users are able to do this independently. The care and support plans also contained detailed risk assessments in relation to day-to-day living and potential risks. The home had reviewed the risk assessments in December 2006 for the care and support plans that were viewed. All documents relating to service users are stored securely, in accordance with the Data protection act 1998. The home has a confidentiality policy. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 12 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 1 4 15 16 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home provides a wide range of activities for all the service users. It appears that more in-house activities are now being provided. The home promotes contact with family and friends. Bridge House consults service users on the menus and provides service users with diets based on cultural needs. EVIDENCE: At the time of the inspection no service users were accessing college, work placement or work experience. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 13 The Expert by experience spent a period of time talking to service users about activities and observing the activities that were happening at the time of the inspection. Staff were also observed how they were interacting with service users and how staff offered service users choices. The Inspector was advised by the Expert by experience, of the following: “The morning I was at the home the residents were having a karaoke morning. I observed some of the residents taking part in this. I thought the staff interacted with the residents very well and motivated the residents to take part and took part themselves”. The Expert by experience spoke to two residents who said the activities are sitting in the lounge, going to the pub and going shopping. One service user added that “Sometimes I decide what to do”. Staff choose activities and I like all my activities”. I go out with staff and go to the shops” The Expert by experience asked about activities in the home and was told, “Sometimes I sweep the floor and wipe the tables. “I do painting”. One service user said that said she sometimes shops for the house and also said “I make some decisions, my key worker asks me if I want to go shopping”. “Sometimes staff think of things, sometimes I do”. “There are enough staff working so I can do activities.” Another service user advised the Expert by experience that she does sewing and knitting and likes karaoke and that she goes out for coffee and cake and goes to the pub. The Inspector also noted that on the day of the inspection service users were being offered a variety of leisure activities and were also assisting in every day activities such as food preparation, cleaning and laundry tasks. Some service users went on holiday to Lyme Regis, Ireland and Newquay. The home records the activities and opportunities that service users undertake. The home has a weekly timetable and the service users are involved in the activities they do. However, the Inspector recommends that the home develop individual timetables for service users wherever possible. This will demonstrate a more person centred approach. The Expert by experience also made the following comments: “I think there are a lot of activities for residents to do on different days. I thought the karaoke was superb and seemed well organised. The residents I saw seemed to be involved in choosing their activities”. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 14 I was impressed with the size of the house, that there was a lot of space but also felt cosy and friendly. I liked seeing the pictures of the residents on the walls as this made it more homely. “I give the home 10 out of 10, the green flag. I felt the staff were caring with the residents and staff knew what the residents wanted which I could tell from the expression on the residents faces”. The home encourages contact with relatives and friends. As part of the inspection process the Inspector sent 9 Relatives/Visitors comment cards. 4 were returned. All returned comments confirmed that the home informs relatives important matters that affect their relative and that the staff welcome them at the home at any time. All relatives stated that they were satisfied with the overall care provided. The home has a planned menu that is developed following seeking the views, likes and dislikes of the service users. Special diets are provided for. One service user has halal food. The staff demonstrated their awareness of meeting the cultural needs of one service user. Service users said that they liked the food. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 15 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 good This judgement has been made using available evidence including a visit to this service. Bridge House ensures service users have access to a variety of health care professions. The home has clear practices for the storage, dispensing and recording of medication but needs to improve on the protocols for the management of some medicines. EVIDENCE: All service users have full en-suite facilities. This further promotes privacy and dignity. Staff that the Inspector spoke to gave examples of how this is promoted. There are no set times for getting up and going to bed. It was noted that service users were well attired. Some female service users were wearing make up and jewellery. One service user has the use of an aid to assist bathing. The home operates a key worker system. The records the Inspector viewed evidenced that the home involves other health care professionals. These Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 16 include GP’s, speech and language therapist, dentist, opticians, psychiatry and psychology services. There are currently no service users independently managing their own medications. The Inspector viewed the MAR sheets and the medication system all of which are very well organised and maintained. However, there were extensive discussions with the Registered Manager and a senior member of the care team as to how the home manages the use of “when required” medication. It was noted that the MAR sheets did not describe why some service users were prescribed “when required” medication. There were not protocols in place for all service users who are prescribed this medication to manage their behaviour. Following these discussions the home must developed protocols to guide staff when such medicines can be used to manage specific behaviours. This is further identified in Concerns, Complaints and Protection part of this report. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 17 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 Adequate This judgement has been made using available evidence including a visit to this service. The home has a robust complaints policy but needs to ensure that all interested stakeholders are aware of the procedure. The home promotes good practice in relation to the management of behaviours but needs to further develop behaviour management guidelines. EVIDENCE: Voyage has a robust Complaints policy and a complaints record. There have been no recorded complaints since the last Inspection. However, since the last Inspection concerns were raised to the Commission for Social Care Inspection (CSCI) about some care practices. These concerns were raised with the home. The home responded in an appropriate manner and reviewed the management of one service users’ living environment. This has had positive outcomes. The feedback received from the relatives comment cards indicted that some relatives were not aware of the home’s Complaints procedure. It is recommended that the Registered Manager take steps to address this. A whistle blowing policy is in place within the home relating to the Protection of Vulnerable Adults and staff spoken to where aware of its contents and usage. The home has a number of systems to safeguard vulnerable people and has a copy of the Safeguarding Vulnerable Adults Procedure. The home has previously taken appropriate steps in relation to the safeguarding of vulnerable Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 18 adults when needed and has kept the Commission for Social Care Inspection informed. Staff have received training in Non-violent Crisis Intervention (NVCI). This training is accredited by BILD. As previously mentioned the Registered Manager must develop protocols for the management of “when required” medicines. It appears that some medicines may be used to support the management of some behaviours. The protocols must be incorporated in behaviour management guidelines to ensure that all staff are consistent in their approach to the management of behaviours and the use of when required medicines. The Registered Manager recognised this and agreed to address this without further delay. Records of financial transactions involving service users finances where not viewed at this inspection. Bridge House DS0000039957.V319035.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 25 26 27 28 29 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Bridge House is homely, clean and hygienic. Service users bedrooms reflect individual lifestyles tastes and lifestyles. EVIDENCE: The Inspector viewed most areas of the home. There are two lounge areas. One is used as a quieter games area and the other has a large plasma TV. There is a large dining room that opens on to an extensive patio area that leads to an attractive rear garden. There is a large domestic style kitchen and domestic laundry facilities. All bedrooms are located on the ground floor and first floor and have full ensuite facilities. The bedrooms viewed were very well presented and have been personalised and reflect the service users individual needs and preferences. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 20 The en-suite facilities were clean and hygienic. One service user has the use of a bathing aid. Service users that the Inspector spoke to stated that they liked their bedroom. Bridge House is decorated and maintained to a good standard. The home has a refurbishment and redecoration programme. The Inspector noted that a leather settee in one lounge area had an extensive rip. It is recommended that the home consider replacing this piece of furniture. On the day of the inspection the home was homely, well maintained, clean and hygienic. Bridge House DS0000039957.V319035.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): 32 33 34 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is proactive in ensuring that staff are competent and qualified. At the time of inspection the home appeared adequately staffed. The home operates a robust recruitment and training and development policies. EVIDENCE: The Inspector and the Expert by experience noted that care staff interacted with service users in a very positive manner. Staff were patient, caring and supportive. Staff have received training in alternative methods of communication, intensive interaction and NVCI. Staff demonstrated their awareness of the needs of the service users. The home is very proactive in promoting NVQ qualification. At the time of the inspection 54 of the care team have obtained an NVQ qualification. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 22 On the day of the inspection it appeared that there were adequate numbers of staff on duty to meet the needs of the service users. Staff spoken to confirmed that they have sufficient staff on duty. There is usually 6-7 care staff on duty of a morning and usually 4 on duty after 7pm. However, the Registered Manager confirmed that the rota is amended to reflect the needs of the service users and to accommodate activities and appointments. The vast majority of comment cards received from relatives/carers indicated that they feel that sufficient numbers of staff are on duty. The Inspector viewed the documentation in relation to recently appointed care staff. The files contained the required documentation as listed in Schedule 2 of the Care Homes Regulations 2001. The home has a robust recruitment process. Bridge House has a detailed Training and Development Plan. All staff have individual training records. Staff have received training in various matters including: heath and safety, first aid, food hygiene, fire, STC, medication, supervisory management, NVCI and infection control. The Registered Manager confirmed that staff are to receive training in the protection of Vulnerable Adults in the near future. Staffs spoken with were complimentary of the training that is on offer. Bridge House DS0000039957.V319035.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 home is well managed. Bridge House promotes matters relating to health and safety however, some areas need attention. EVIDENCE: Mr Guy has previous experience of managing a service for people with a learning disability, as he was a Registered Manager of a service until his recent appointment at Bridge House. He has approximately 13 years experience in working with people with a learning disability and additional complex support needs. He has undertaken a variety of training relevant to his role. He has Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 24 registered to undertake NVQ4 in Care. Mr Guy has a Certificate in Management Studies. The home has various systems to quality audit the service that they provide. Policies and procedures are updates as and when required. Bridge House has recently implemented residents meetings as a first step to seek the views of service users. The Inspector was advised that service users are consulted about their views as much as possible. However, the home has yet to seek the views of family, friends and other interested stakeholders in the community. This must be addressed. The Inspector viewed a variety of health and safety records: Fire Safety: The home keeps detailed documentation in relation to fire safety and management. Regular fire drills are conducted and staff receive regular fire training. The fire system was serviced on 21/11/06. Emergency lighting test are conducted monthly. The home’s fire risk assessment is dated 29/11/06. The fire fighting equipment was serviced on 16/11/06. PAT: Portable appliance testing was conducted on 15/05/06 Electrical Hardwiring Certificate: This is dated 20/12/02 Gas Safety Certificate: This is dated 20/05/06 Legionella and Hot water: A certificate was issued in September 06. Regular checks are made of the hot water outlets. Fridge/freezer temps: Daily checks are made of fridge and freezer temperatures. Environmental risk assessments: A number of these have been completed and have recently been reviewed. Arjo Aqua-Tec: This was serviced on the 04/12/06. It was noted that in one identified bedroom the wardrobe was not secured to the wall. The Registered Manager must complete a detailed risk assessment or arrange for the wardrobe to be secured. The Inspector viewed a number of accident and incident reports. It was noted that on some occasions, accident forms had not been completed following an incident that had resulted in an accident. It was also noted that accident forms had not been completed following a specific accident. This was bought to the attention of the Registered Manager at the time of the inspection and must be addressed. It is recommended that the Registered Manager countersigns all accident /incident records as part of the audit process. Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 25 Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 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 2 X X 3 X Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 (2) Requirement Timescale for action 2 YA23 15 (1) 3 YA42 4 YA42 17 (1) (a) Schedule 3 of the Care Homes Regulations 2001 13 (4) (a) The Registered Manager must ensure wardrobes are secured or detailed risk assessments are conducted. The Registered Manager must develop protocols for the 28/02/07 management of “when required” medicines. The Registered Manager must ensure that all behaviour 30/03/07 management guidelines include the protocols for the use of “when required” medicines. The Registered Manager must keep a record of any accident 10/03/07 affecting the individual service user. 10/03/07 Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 28 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 YA13 YA22 Good Practice Recommendations The Registered Manager should develop individual service user activity timetables wherever possible. The Registered Manager should ensure that all interested stakeholders are aware of the home’s Complaints procedure. The Registered Manager should consider replacing the identified settee in a lounge area that has a large rip. The Registered Manager should develop quality audit questionnaires. The Registered Manager should countersign all accident and incident records as part of the audit process. 3 4 5 YA24 YA39 YA42 Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI Bridge House DS0000039957.V319035.R01.S.doc Version 5.2 Page 30 - 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. 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