Inspection on 09/10/07 for Bridge House

This inspection was carried out on 9th October 2007.

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 11/07/06

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 9th October 2007 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.V347477.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.V347477.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 bh1europeancare@aol.com www.europeancare.net European Care (UK) Limited Mrs Pamela Elizabeth Rooney Care Home 34 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (34) of places Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - Code PC, to service users of the following gender – Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE (The maximum number of places: 10) The maximum number of people who can be accommodated is: 34 Date of last inspection 11th July 2006 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 £357.00 to £441.00, 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.V347477.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 inspection was carried out over one day, between the hours of 9.30am to 4.45pm. During the visit time was spent looking at paperwork and the environment as well as observing staff interactions with residents. The inspector also spoke with residents, relatives, staff and the manager. Before the inspection, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home sees the service they provide the same way that we do. Feedback was given to the manager about how the form could be developed in relation to the level of information provided. Feedback surveys were also sent to service users and staff however had not been received due to the postal strike. The home is registered to provide accommodation for 34 people. There were 5 vacancies at the time of the visit. All the key standards were looked at during this inspection visits as well as the action identified during the last visit. What the service does well: Bridge House is a large home set is it’s own grounds. There is ample parking for visitors and well-maintained gardens, which have been adapted to meet the needs of residents. Overall, there have been no changes within the staff team since the last inspection visit therefore providing a stable team in sufficient numbers, who are aware of the needs of residents. The manager and staff appear to enjoy their work and have an open and friendly relationship with residents. The inspector spoke with a visiting relative as well as residents whilst at the home. Some of the comments received about the care and support provided include; ‘the girls were lovely’, ‘we have a good laugh and enjoy doing things’, ‘no complaints, I couldn’t see myself living anywhere else’, ‘I like the food, it’s very good what they make’, ‘the manager and staff are wonderful’, ‘the manager responds to things quickly’ and ‘mum is very settled, has her own room with lots of her things around her’. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Assessments and care plans need to be developed so that they clearly reflect the current and changing needs of residents providing staff with guidance on what support is to be provided based on the needs and wishes of people. The manager is aware that a system of staff supervision needs to be developed to ensure that they receive the support and guidance in carrying out their role and responsibilities. A staff training matrix is to be provided showing what training staff have completed and what they still need to do as well as the dates they are to attend. This will ensure that they have the knowledge and skills required to meet the needs of the residents living at the home. Copies of the GSCC code of practice booklets have been accessed and should now be handed out to each member of the team. All new staff must complete the skills for care induction training on starting their employment to ensure that they have the information and training necessary to do their job safely. When recruiting new staff, files should evidence that all checks have been carried and that people have been properly vetted ensuring residents are protected. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 7 A copy of the homes refurbishment plan is to be sent to the CSCI showing what further work is to be carried out to further improve the appearance of the home. In relation to health and safety, records need to be maintained showing that regular water temperature checks have been done. A copy of the gas certificate and any incidents reports where this may have affected the wellbeing of resident should also be forwarded to CSCI. The manager must ensure that she completes the NVQ level 4 and registered managers award, which is relevant to her role and responsibilities. One of the areas the home could explore is an annual report about the home based on the feedback from residents and other parties about the quality of service provided and how this will inform any future plans. 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 DS0000008412.V347477.R01.S.doc Version 5.2 Page 8 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.V347477.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents should not move into the home unless a comprehensive assessment is undertaken and evidences that the home is able to meet their identified needs. EVIDENCE: Due to the changes in registration the home was asked to review and up date the Statement of Purpose so that information reflected the services now being provided at the home. This has been done. The document provides details about the Provider and Manager as well as more specific details about the aim of the home, who it caters for, what care and support is provided and specific policies in relation to admissions and complaints. As outlined within the Statement of Purpose further information is also provided about the home within the ‘Home Pack’, which is given to all new Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 10 residents who move into the home. This includes the home’s brochure, service user guide and individual contract agreement. Within the Statement of Purpose is a copy of the home’s admission policy. This discusses prospective residents being assessed prior to any decision being made and may include information being provided from other health and social care professionals as well as the Bridge House pre-admissions assessment form. One of the files examined was for a new resident who had recently moved into the home and required care and support due to her dementia needs. Information included a pre-admission assessment and admission assessment. These had been carried out by a member of staff from the home. No information was seen from the funding authority. On examination the preadmission assessment was incomplete, there was no information about the persons medical history, practical skills, routine or interests. The residents name had not been added to the top of each sheet and the document had not been dated. The same was noted with the admission assessment, this too was incomplete and had not been signed or dated by the person completing the forms. So that the home is able to fully meet the needs of residents it should ensure that people are only admitted on the basis that a full assessment is undertaken by someone trained to do so and in such detail that they are able to ensure that they are able to meet the identified needs. This information is then used to inform the development of a care plan. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information about the health and personal care needs of residents needs to be expanded upon so that plans clearly reflect their needs and wishes and how they are to be met. EVIDENCE: Files were looked at for 3 residents, one who had recently moved into the home, the second was privately funded and the third had been in poor health on admission. Time was also spent speaking and observing 2 of these residents. Each of the files were orderly and contained the assessment, care plan, risk assessments, record of professional visits and property checklist. Care needs to be given when making photocopies of forms as some of the information needed was missing and was therefore not easy to read or completed in full. The completion of the care plan and risk assessments also varied, whilst some documents provided a good overview of the persons needs and how they were Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 12 to be supported, others were vague offering no guidance or direction to staff. An example being, when asked about social involvement information stated ‘yes’. There was no information about what kind of involvement, who with, when or how often. In relation to diet the form stated ‘yes’ with no further information about the resident having a poor diet and requiring prompts and encouragement from staff to take meals. Information about the new resident who had been admitted due to her dementia care needs, did not detail her diagnosis or any specific health and care needs or why she had been referred to the home. In relation to risk some assessments held on one file had not been scored properly. Areas such as weight or neurological conditions had not been scored on the nutritional assessment. The skin condition on the same assessment had been identified as being dry/inelastic however this did not reflect what had been recorded on the water low assessment. Further omissions/errors were made on the water low assessment in relation to the person’s neurological states not being scored and their age had been recorded as 81 years and above when the resident’s actual age was 69 years. More care and attention must be given by those staff completing the assessments and plans so that information accurately reflects the current and changing needs of residents. Where necessary consideration should be given to additional training ensuring they have the knowledge and skills required. Assessments in relation to wound care and continence management are undertaken with the support and advice from the district nurse and continence advisor. Any identified support needs are then added to the care plan. Each of the residents are registered with GP’s and have access to other health care professionals as and when required to ensure that the health and well-being is maintained. Additional records are also completed by staff. These include daily reports, a handover book, which is used during shift changes and medication records. There are also separate nursing files for those people requiring support from the district nurse. The organisation has recently drafted a new assessment and care-planning document. This had been forwarded to managers for feedback. The manager felt that some areas were not specific to her service as nursing care is not provided. The medication system was looked at. Items are stored in 3 trolleys, 1 for morning and lunchtime meds, 1 for evening and night time and the third for additional stocks. These are kept in the ground floor staff office or in the dining room whilst in use. Records are made of all items received by the home and those items returned to the supplying pharmacist at the end of each Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 13 month. Individual records are held for each resident with a photograph for identification. Record sheets had been completed and signed to evidence administration. The manager was advised that hand written entries should be signed and countersigned to ensure that the information records reflects that on the prescription. Controlled drugs are also held. Suitable lockable storage is available as well as a drug register. Records had been signed by 2 staff on administration. Interactions between residents and staff were warm and friendly with good humour. The inspector sat with 2 residents over the lunch period. Both agreed that ‘the girls were lovely’. Other comments included, ‘we have a good laugh and enjoy doing things’ and ‘no complaints, I couldn’t see myself living anywhere else’. Comments received from other people were also positive. One person stated that ‘the manager and staff are wonderful’, ‘the manager responds to things quickly’ and ‘mum is very settled, has her own room with lots of her things around her’. Bridge House DS0000008412.V347477.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines within the home are based on individual wishes and preferences with opportunities to follow social, cultural and recreational interests of their choosing. EVIDENCE: Since the last visit the home had employed an activities co-ordinator who has unfortunately left the home. This had been a great asset providing a variety of opportunities for residents. These are currently being carried out by staff within the home until another worker is recruited. Some of the activities include arts and crafts, bingo, quizzes and an occasional entertainer. On the day of the visit residents enjoyed a game of ‘name that tune’ and exercise to music. The home also holds ‘themed days’, such as St George’s etc. Plans were also being made for a Halloween party. Outside activities also take place with some residents attending the local community centre or St John’s church hall where they have lunch, play bingo or enjoy the entertainment. Communion is also held at the home each month. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 15 As already stated a sensory garden has been developed providing a pleasant garden with seating for residents to enjoy in safety. Money was donated from the League of Friends towards plants and flowers for the garden and the Mayor was invited for the opening. The inspector also looked at 3 ‘life history books’, which are being developed with 3 residents, these include old photographs of their family and lives providing opportunities to reminisce about their past. Pictures and memory items are also to be placed in frames on bedrooms doors to act as reminders for residents with dementia. Residents continue to enjoy regular contact with family and friends. Family members again expressed that they are always made welcome when visiting the home and refreshments were provided. Residents were said to enjoy watching the television, having birthday parties and newspapers and magazines are delivered to the home. Each of the residents have their meals in the spacious dining room, which is easily accessible to those residents with walking aids or who need support. Small tables are provided and are nicely set with tablecloths, flowers and cruets. The dining room has been identified for redecoration now that the new kitchen has been completed. The kitchen is staffed all day with a cook and kitchen assistant available between the hours of 8am and 5pm. Arrangements for meals are relaxed with breakfast between the hours of 8am and 10am for those who do not rise early, lunch from 12 noon and tea from 4.30pm. Supper is also available at 7 and 9pm. Drinks are also served at regular intervals. Where necessary build up drinks are also provided. Those residents requiring assistance are supported by the staff. A variety of meals are offered with the lunch being the main meal of the day and comprising of 3 courses. A hot and cold option is also available at teatime. The cook had also spent time baking, preparing a chocolate sponge for after lunch and chocolate cookies for later in the day. One resident commented, ‘I like the food, it’s very good what they make’. Bridge House DS0000008412.V347477.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements are in place in relation to the protection of residents as well as responding to their concerns. EVIDENCE: A copy of the home’s complaints procedure is displayed within the home so that it is easily accessible to residents and visitors. Further information is also provided in the information provided by the home. This tells people how their concerns/complaints will be dealt with as well as having contact details for CSCI. No concerns, complaints or allegations have been identified within the AQAA, nor have any issues been raised with us. Further procedures are in place with regards to the protection of residents and a number of staff have received training in this area. The home is a member of the Bury Partnership Training Group, which is to provide further training for both staff and managers on the new Inter Agency Procedure held by Bury. The manager may wish to access this particularly for those who have not had the training or as a refresher for other staff. Management training will include the reporting and responding to any allegations made in line with the Procedure. Other policies and procedures are in place with regards to ensuring the safety and protection of residents and staff. These include missing persons, Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 17 recruitment, dealing with violence and aggression and management of residents’ finances. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bridge House continues to be improved to provide residents with comfortable accommodation in pleasant surroundings. EVIDENCE: Bridge House employs a number of ancillary staff that ensures the home is clean, tidy and maintained to a good standard. There is a full time maintenance man, 2 full-time cooks, 2 kitchen assistants plus a housekeeper, 3 domestics and a laundry assistant, providing cover throughout the week. The home has recently changed its registration to provide some accommodation for people with dementia. Ten rooms have been identified and recommendations were made in relation to adapting the environment to suit these needs. This has been done and included redecoration of hallways and a lounge, extra lighting, new carpeting, additional internal doors and coded locks Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 19 to offer additional security. The internal phone tannoy system is now no longer in use and the kitchen has recently been refurbished. Discussion was held with the manager about further work required within the home. This will include redecoration of the dining room and 2 other lounges. Arrangements have already been made for some replacement armchairs as the current ones are looking tired and worn. The manager is asked to send a copy of the homes refurbishment plan along with timescales for completion to us. The home has large mature gardens to the front and side of the property, which have been well maintained. As already stated work has been carried out providing a secure sensory garden for resident to relax in. Further work is planned with the support of the probation service, which will include raised flowerbeds so that those residents with limited mobility are still able to join in with the gardening. Some resident had spent time making a mosaic ‘welcome’ sign for the garden to hang on the wall. Within the home, there are 28 single rooms and 3 double rooms. All rooms on the ground floor have en-suite toilet facilities. There are a further 3 bath/shower rooms available plus separate communal toilets. Aids and adaptations have been provided as well as handrails along hallways to aid residents’ mobility. Additional items have also been placed within the home to ensure the safety of residents, particularly those who wake during the night as well as those who may wander. Self-closing devises have been fitted to doors for residents who do not like their doors shut at night. One room looked at also had a sensory pad on the floor so that staff would be alerted if the resident got up during the night and there is also a sensory alarm, which is used by staff at night to alert them if someone is moving around the home. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing at the home is stable and in sufficient numbers, however some improvements are needed in recruitment and training to ensure that residents are safe and supported by competent staff. EVIDENCE: Staffing at the home has remained stable since that last visit. The only changes have been a new carer who recently started work and the activities co-ordinator leaving. This position has been re-advertised. Three staff personnel files were looked at, this included recruitment as well as supervision and training. Files seen were for the new member of staff, a senior carer and a cook. Overall recruitment information included application forms, health declaration, 2 written references and contract of employment. One minor shortfall was that gaps in employment had not been explored. In relation Criminal Record Checks, this had not yet been received for the new member of staff however a POVA 1st checks had been completed. There was no evidence of CRB disclosure being received for the 2 existing staff. Further guidance is provided from the Criminal Records Bureau and CSCI website in relation to what information should be held for existing staff. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 21 Rotas were looked at for the 4 week period up to the visit. Sufficient staffing had been provided. Cover generally comprises of 4 staff between the hours of 8am and 4pm, 3 staff between 4pm and 8pm and 3 night staff. The manager and deputy manager are also on-call should any further support be required in the event of an emergency. The home does not use agency cover as staff are willing to do overtime. The manager said that she has ‘every confidence in her staff’. It was noted that the staffing rotas do not identify which staff are caring for those residents with dementia. The manager explained that this is because residents with dementia do not have separate facilities. Each resident is able to access all communal areas within the home and therefore the staff work together as a team. Training records were also looked at. The manager explained that all staff have completed some dementia training, ‘Yesterday, Today and Tomorrow’ and a second part is to be completed, which will then be assessed and accredited by the Alzheimer’s society. Evidence of such training should be held on file. The manager recognises that further training needs to be planned with regards to up dates of mandatory courses, adult protection and topics specific to the needs of the home. A plan of training is to be drawn up based on the courses available through the Bury Adult Care Partnership Training Group, which the home is a member of. The manager is asked to send us a copy of the staff training matrix, which shows what training staff have had along with future training plans and dates of courses. NVQ training has also been provided for staff. Of the 18 carers, which include the deputy manager, 9 have completed level 3 and 4 have completed level 2. Two staff have now progressed onto the level 3 course and another member of staff has commenced level 2. Two further staff will be enrolled at the next intake. The Manager holds Level 3 and is soon to commence level 4 and the registered managers award. The manager has now received copies of the GSCC code of practice booklet, these are to be distributed to each member of the team. Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager strives to provide a service, which is ran in the best interests of residents and recognises areas for further improvement so that the team is able to meet it’s aims and objectives. EVIDENCE: As previously identified the manager has a considerable number of years experience working with older people in both care and management. She has completed her NVQ level 3 however has yet to complete the Level 4 and Registered Managers Award. Due to issues with training providers this has been delayed, alternative arrangements are now being made. The manager works at the home on a daily basis, generally weekdays and is supported by a deputy manager and administrator. She is managed by the Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 23 Programme Manager who visits the home on a weekly basis. The manager said that she had a good relationship with her manager and receives ‘wonderful support’. With the changes in registration the manager and staff have also had support from the organisations Dementia Development Manager, who has provided guidance on the environment and support. His input was described as ‘brilliant’ and that ‘he can be contacted at anytime if we need any advice about anything’. The manager also has the opportunity to meet with other registered managers within the organisation, providing further opportunity for them to discuss any issues as well as share ideas and information. The inspector spoke with the manager about the new inspection process. As already stated the manager had completed and submitted the AQAA prior to the inspection taking place. This provided quite a lot of information about the what the home was doing, areas of improvement and some of their future plans. The National Minimum Data Set for Skills for Care had also been completed. This had been undertaken for the organisation as a whole, registering as one body. Specific information about Bridge House was being gathered so that this too could be submitted. With regard to quality assurance, monthly monitoring visits are carried out by senior management on behalf of the Provider and copies of their reports are held at the home. Customer satisfaction surveys are due to be sent out in October, these are sent to families requesting feedback about the service provided. It was asked if these were also sent to health and social care professional that are known to the home. This is not generally done but it was said that it could be considered. The home is also to be reassessed at the beginning of 2008 for the Investors in People Award (IiP), the manager is to attend a local conference, which will outline what evidence is to be provided. The manager has previously invited relatives to ‘evening clinics’ to discuss any issues they may have, but this has rarely been used. Team meetings and resident meetings are also held providing an opportunity to gain feedback and comments about the home and areas of improvement. The manager needs to consider developing an annual report specifically for Bridge House based on information and feedback from residents and other stakeholders. This would identify what the home does particularly well, as well as areas of further improvement that they wish to look at over the forthcoming year. The inspector did not look at residents’ finances and how these are managed. No issues were identified at the previous visit. Discussion was held with the manager about staff supervision. The manager explained that these had not been carried out as frequently as they should due to other issues. Consideration was being given to some of the responsibility being delegated to other senior staff, for example the manager to supervise Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 24 the deputy and senior carers, the deputy manager to supervise the care staff and the housekeeper the ancillary staff. This would make the task more manageable if shared. The homes maintenance man undertakes checks in relation to health and safety. He has responsibility for all general repairs, in-house fire safety checks including drills, temperature checks and pat testing. Records were looked at. Information regarding water temperatures was available for the month up to August 2006 and then nothing until September 2007. Some of the information needs to be archived so that only current records are held within the files, this will ensure that records are accurate and up to date. Servicing is also carried out on the bath hoists, portable appliances, electrics, gas supply, stair lift, ventilation and fire alarm and lighting. The up to date gas certificate was not available, as the check had only recently been carried out. Once received the manager is asked to send a copy to us. In relation to accidents and incidents, information stated of the AQAA refers to 6 admissions via A&E and 4 deaths at the home. None of these incidents had been reported to us in line with the regulation. The manager should complete a regulation 37 notification form and send it to us so that we are aware of events, which affect the welfare of residents. Bridge House DS0000008412.V347477.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X 2 Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 12 Requirement A comprehensive assessment should be carried out to ensure that the home has all relevant information about the needs of prospective residents prior to moving in ensuring placement is suitable. Timescale for action 30/12/07 2. OP7 15 Care plans need to be completed 30/12/07 in sufficient detail so that they clearly identify how each resident’s needs are to be met as outlined within the report. Document should be dated and signed by the person completing the form. Outstanding requirement – 31.01.06 & 30.9.06 3. OP7 15 Risk assessments need to be completed in full and accurately reflect the needs of residents ensuring the appropriate level of support is provided. 30/12/07 Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 27 4. OP7 15 Residents and their relatives/representatives should be encouraged to sign the care plans evidencing their satisfaction and involvement. Outstanding requirement 30.9.06 30/01/08 5. OP29 19 Staff recruitment files must 30/12/07 evidence that contain all relevant information and checks have been carried prior to staff commencing employment Outstanding requirement – 30.9.06 The manager is asked to provide 30/12/07 a copy of the staff training matrix identifying the training needs of staff along with dates of courses to be attended ensuring all training is up to date in relation to their role and responsibilities. That the Manager ensures that all staff receive supervision on a bi-monthly basis and discussions are dated and signed by both parties. Outstanding requirement – 30.10.06 30/12/07 6. OP30 18 7. OP36 18 Bridge House DS0000008412.V347477.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. Refer to Standard OP9 Good Practice Recommendations Hand written medication sheets should be double signed to ensure that the information recorded accurately reflects what has been prescribed. The Manager is asked to forward a copy of the homes refurbishment plan to the CSCI outlining work, which has been identified and timescales for completion. Copy of the GSCC code of practice booklet should be distributed to each member of the team The manager must make arrangement to complete the NVQ level 4 and Registered Manager Award as required for her role. That consideration is given to developing an annual report based on the feedback from residents and other parties about the quality of service provided and how this has informed future plans. A copy of the recent gas certificate should be forwarded to CSCI. Up to date records regarding the water temperature checks should be held on file. 2. OP19 3. 4. OP29 OP31 5. OP33 6. 7. OP38 OP38 Bridge House DS0000008412.V347477.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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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