Inspection on 19/06/08 for Bridgemarsh

This inspection was carried out on 19th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bridgemarsh 25/05/07

Bridgemarsh 24/05/06

Bridgemarsh 04/10/05

Bridgemarsh 03/05/05

Bridgemarsh 08/09/04

Bridgemarsh 06/05/04

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Bridgemarsh 184 Main Road Broomfield Chelmsford Essex CM1 7AJ Lead Inspector Pauline Marshall Unannounced Inspection 19th June 2008 09:30 Bridgemarsh DS0000034854.V367883.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 Bridgemarsh DS0000034854.V367883.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. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridgemarsh Address 184 Main Road Broomfield Chelmsford Essex CM1 7AJ 01245 440858 01245 442239 norman.wagstaff@essexcc.gov.uk www.essexcc.gov.uk Essex County Council 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) Mr Norman Richard Wagstaff Care Home 28 Category(ies) of Learning disability (28), Learning disability over registration, with number 65 years of age (1), Physical disability (6) of places Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 28 persons) Persons of either sex, under the age of 65 years, who require care by reason of a learning disability and who also have a physical disability (not to exceed 6 persons) One named person, over the age of 65 years, who requires care by reason of a learning disability The total number of service users accommodated in the home must not exceed 28 persons 25th May 2007 Date of last inspection Brief Description of the Service: Bridgemarsh is a purpose built home providing accommodation and care on a unitised basis. All bedrooms provided are single. The home provides accommodation for people with a learning disability, aged from 18 to over 65. Peoples’ support needs vary from being low to high dependency. People living in Bridgemarsh are provided with a range of shared facilities both inside and outside of the home. The home is situated on a local bus route that serves the town centre, shops, recreational and public services. The home also has access to community transport facilities. People using the service are provided with a copy of the homes Statement of Purpose and Service User Guide. The cost of a bed space at Bridgemarsh is £1,221.67 per week; people pay a contribution towards this that has been assessed according to their individual circumstances and the amount varies. There are additional charges for hairdressing, toiletries, magazines and newspapers, holidays, trips out, eating out, clothing, chiropody and transport. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection that lasted nine hours and forty-five minutes. The process included discussions with people living in the home, the manager and the staff; examination of a random sample of the files (including those of staff and people living in the home) and some of the records that the home is required to keep. The inspection covered all of the key standards and included a tour of the property. The manager completed his annual quality assurance assessment (AQAA) and information from this has been reflected throughout this report. An expert by experience assisted us with the inspection and he focused on how it feels to live at Bridgemarsh, the activities that are offered and the quality of the meals; his valuable input has been included in this report. Surveys were sent to the manager to distribute to twenty people who live or stay at the home, twenty of their relatives, six health and social care professionals and twelve care staff. At the time of writing this report six people using the service, two of their relatives, one health and social care professional and three staff surveys had been returned. The returned surveys contained mainly positive comments about Bridgemarsh and comments are reflected throughout this report. What the service does well: The home gives people good up to date information on the service it provides and offers people the chance to visit before moving in. People living in the home are encouraged to make decisions about what activities they want to do, both in and out of the home and what and where they want to eat. People said they were happy living at Bridgemarsh. The manager listens and acts upon people’s complaints and generally resolves issues on a day-to-day basis through discussions and meetings. The staff team are stable and people say they feel well treated by the manager and his staff. The home is clean and tidy. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager should make sure that each person living at the home has a contract. Care plans must be fully completed and give detailed information on how staff is to meet peoples needs; they must include the persons view and wishes and be regularly reviewed. All risk assessments must include plans on how to manage identified risks and must be reviewed regularly. The manager and staff should continue to develop activities for people living in the home. The manager must make sure that there are detailed instructions on the use of as and when prescribed medication and homely remedies. Staff must make sure that all medication given is signed for and that if medication is not given they must enter the right code on the medication sheet. The manager must make sure the rota shows, which staff is sleeping in and which staff are awake. All of the staff files must contain the documents listed in the regulations. The manager should provide staff training in risk management, challenging behaviour and updated training in adult safeguarding. The manager should make sure that all staff receives appropriate supervision. The manager must make sure that the quality assurance system includes internal audits of his business systems and that he seeks the views of all interested parties when carrying out surveys. The manager must make sure that the homes electrical system is safe and that he holds an up to date certificate that states the electrical system is satisfactory. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 7 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. Bridgemarsh DS0000034854.V367883.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 Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to receive a thorough pre-admission assessment and up to date information on the home prior to their admission. EVIDENCE: The Statement of Purpose was last reviewed in March 2008 and the Service User Guide on 23rd April 2008. The Statement of Purpose included up to date information on the service including staff qualifications and details of the size and facilities of each room. The Service User Guide is written in large print and states that it can be made available in alternative formats that include Braille, pictorial and other languages. There have been no permanent admissions to Bridgemarsh since the last inspection. The last person admitted on a permanent basis was in April 2007 and the manager had carried out a thorough needs assessment in addition to the Social Services assessment (COM5). The person made several visits to the home and had stayed for respite on several occasions before moving in permanently. People living in the home said that they had made visits and stayed there before moving in. The manager said that unless people are admitted to Bridgemarsh in a crisis situation they are offered the opportunity to make tea visits and overnight stays before admission. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 10 Essex County Council Social Services Care Management team has placed each person living in the home both permanently and for respite. There was no evidence of a contract on the care files examined, however the manager said that each person staying at the home is on license and that some have placement agreements and that he has discussed the need for people living in the home to have contracts with his line manager. There were copies of emails available that confirmed the manager’s actions. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The inconsistent approach used in the care planning system could potentially affect any positive outcomes for people living in the home. Whilst people can expect to be supported to make decisions about their lives, they are not fully supported in risk taking. EVIDENCE: The manager has put in place a new care planning system that has provision for people living in the home to be fully involved in its production. Four care files were examined and they all contained a copy of the new “service user plan”. It was evident from the new plans that some people living in the home had been involved in its creation. One person spoken with confirmed that the care plan details were correct and that they felt that it met their needs. The level of detail varied in the completed plans and two of the four examined were not fully completed. The manager said in his Annual Quality Assurance Assessment (AQAA) “care plans are tailored to meet individual needs and aspirations and that people are central to the development and implementation Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 12 of their own care plan”. The expert by experience said in his report “staff did not know about person centred plans but one of the residents knew about them”. The two care plans that had not been fully completed had minimal information on how care was to be provided and they did not demonstrate that the person living in the home had been involved in its creation. Each of the four care files examined contained out of date paperwork, including old reviews, charts, assessments and health related letters. It was difficult to locate current information within the care files and one of the care files examined showed that the last review was held in 2005 and on further searching in the file there was evidence that a review had been held in 2008. The care files also included different forms for recording health related visits, some were completed and others not and again by searching through the files some up to date information was there but difficult to find. Since 1st February 2008 all people living at Bridgemarsh permanently have their own individual diary where their daily notes and activities are recorded. The recording in the three diaries examined was generally clear and informative, however an activity that had taken place the previous day had not been recorded in the diary. The staff member said that they had returned from their pub lunch late and were due to go off shift so did not have the time to record the activity. The daily notes for people staying at Bridgemarsh for respite are written on separate sheets and retained in their care file. The manager said that people tend to return frequently for respite stays and care files are kept active though locked away safely between respite stays. People spoken with said that they met regularly with staff and each other to discuss the running of the home. The manager said that some notes are kept of the meetings and are stored on each individual unit, however many informal meetings that are not recorded take place on a daily basis. People living in the home confirmed this and the expert by experience said in his report “meetings are held every 4-6 weeks with the staff and the residents” and “one resident is involved with the People’s Parliament and advocacy, he can use the telephone and internet and also gets involved in the interviewing of new members of staff”. There were risk assessments in place on the four care files examined, they varied in detail and did not always have a clear plan on how to manage the identified risks; they covered areas of risk both inside and outside the home including social activities. On some of the risk assessments examined it was not always possible to determine when the risk assessment had been carried out as they were not signed or dated therefore it was not possible to establish if the risks were current. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 13 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, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to participate in appropriate activities both in the home and out in the local community and they can expect their rights to be respected in all aspects of their daily lives. People living in the home can expect to be provided with a healthy and nutritious diet. EVIDENCE: People living in the home said that they attended colleges and day centres and that they went shopping in the local town centre; there were entries in the three diaries that were examined confirming that regular activities take place. People access local leisure facilities such as the cinema and bowling and the care files examined contained evidence of trips out for pub meals and to other local facilities. People spoken with and surveyed said that they “go to computer classes and arts and crafts and enjoy going to college and have plenty to do”. The expert by experience said in his report “one resident said he likes gardening and that he is supported to attend the Young Farmers Club” Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 14 and “residents are supported to go on outings, pubs and clubs and one resident said he likes going to the Gateway club and has friends there and is free to invite them home when he wishes”. The expert by experience also said in his report that “staff supports residents with their shopping and that residents like living at Bridgemarsh and they like the people they live with”. The views of people living in the home varied in the surveys that were returned and included comments that “it is not always possible to go out on the spur of the moment” and “I make the decision when I want to go out or when I want to visit my family” and “I would like to go to the zoo, but I must wait until staff can take me”. Staff said in their surveys “it can be difficult to take individuals out spontaneously, outings must be planned and may necessitate group outings, rather than individual trips out and this can be frustrating for the individual and also for the staff”. One relatives survey said “I think they could be taken out for shopping more often” and a staff survey supported this view saying “outings must be planned due to financial restraints/staffing levels and are sometimes in groups when individual trips would be better for the person”. The expert by experience said in his report “a member of staff said that residents do not go on holidays any more as there is not enough money to pay the staff”. The administrative assistant said that she is looking at the possibility of holidays being provided by a holiday provider but nothing has been finalised as yet; the manager confirmed that this might be an option in the future. From talking to people living in the home it was clear that staff encourage them to maintain their relationships with family and friends. The manager said that there was an open visiting policy and relatives said in their surveys “they support my relative very well in the home and help us to keep in touch” and “my relative is happy in the home and happy with the people in the home”. People spoken with said they had a key to their own room and that if staff wished to enter they always knocked first and waited to be invited in. From observation of staff interaction with people living in the home it was evident that people were treated respectfully and that they felt comfortable and relaxed in staff presence. People spoken with said, “the staff and manager treat me very well and listen to what I have to say”. The routine in the home appeared to be flexible and meet the needs of the people living there. People spoken with said how they cleaned and tidied their own rooms with staff assistance. The expert by experience said in his report “resident’s privacy is respected – this was evident when one of the residents took us round the home, he only pointed at other people’s rooms and opened his own room only”. The expert by experience also said in his report “residents have a choice of when to go to bed and choose what to do during the day”. The expert by experience said in his report that a staff member did not call a resident by his name and did not even tell him where they were going but said Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 15 to him “shuffle on you lets go”. Staff interaction was observed throughout the day and no other occurrences of this nature were witnessed. There is a large main kitchen where meals are mainly prepared and the home employs a full time cook and a part time assistant cook. The menus were examined and they contained a variety of nutritious home cooked meals and an alternative choice was offered at each mealtime. The lunchtime meal was a choice of sandwiches, baguettes, pizza and salad and pasta salad; the cook said the main meal was prepared in the evening as most of the people living in the home are out throughout the day. There were fresh vegetables and home made shepherds pie on the evening menu and an alternative was available; the food was well presented, tasty and supplied in ample portions. People on special diets, including peg feeding had detailed information in their care files on how this is managed. The expert by experience said in his report “residents have a choice of what they eat, but the cook does the menu and the lunch was prepared in advance and the residents went into the kitchen to have a pick of what was offered”. The expert by experience also said in his report ”there is no picture menu to choose meals from and during lunch there did not seem to be any specific place for the residents to have their meal; one sat in front of the TV, another in the hallway; the cook and the manager said it was different at dinner time as the staff took hot meals on hot trolleys to the various units and served hot meals there”. The manager said that some people staying in Bridgemarsh have difficulty when choosing what they wish to eat from the homes written menus; so he is in the process of devising a pictorial menu to assist people in making appropriate choices on what they want to eat and drink. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can expect that their physical, emotional, health and personal care needs will be met in a way that they prefer but the homes medication practice does not always provide them with positive outcomes. EVIDENCE: People using the service said they were happy living at the home and that staff worked with them when providing personal care and that the staff knew when they needed help and always respected their privacy. There was specialist aids and equipment available and staff have been trained in its use. The home operates a key worker and co key worker system and the manager said that each key worker together with the co key worker will ensure that people living in the home attends any health related appointments. The manager also said that if it was not possible for either the key worker or co key worker to accompany the person to medical appointments by swapping or changing their shifts, they would arrange for another staff member to attend. There was evidence on the four care files examined that people’s healthcare needs are met and that medical assistance is sought in a timely manner. The manager said in his annual quality assurance assessment (AQAA) “we work Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 17 closely with the community nurse on health action plans”. There was evidence of health action plans in the care files examined. Boots Pharmacy supplies medication for people who live permanently in Bridgemarsh in a monitored dosage system, which is accompanied by a MARS (medication administration sheet). People staying on a temporary basis bring their medication into the home in various forms and the staff prepares a medication sheet where all medicines and creams are recorded and staff initial the medication sheet to confirm administration. A random sample of both types of medication and their corresponding record sheets was examined and were mainly found to be correct. The exception was a MARS (medication administration sheet) that had two gaps in it; staff said that the gap was due to the person being in hospital that day and staff had forgotten to enter the code that should be used when medication is not administered for any reason. Quite a few of the MARS (medication administration sheets) identified that people living in the home were prescribed PRN (as and when medication) and there was no protocols in place to inform staff when, why and how to administer. There were also no protocols for the use of homely remedies. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to have their complaints acted upon and to be protected from harm and abuse. EVIDENCE: The manager records all complaints and concerns in his complaints folder and has recently prepared the homes pictorial complaints procedure that is available to all people living in the home and their relatives. The manager said there have been only minor complaints since the last inspection and these were recorded in the complaints folder. The manager said in his annual quality assurance assessment (AQAA) “most complaints and concerns are dealt with day to day through discussions, meetings and care reviews”. The home works to the Essex County Council complaints policy that was last reviewed in April 2008. The expert by experience said in his report “residents know who to talk to if they needed to make a complaint”. People using the service said in their surveys “staff always listens to me and act on what I say”. The manager said that all policies including the adult abuse policy are prepared by Essex County Council and that the home does not have its own local policies. The abuse policy was last reviewed in July 2007 and the Whistle blowing policy in 2000. The manager said in his annual quality assurance assessment (AQAA) “all staff have POVA (adult safeguarding) training and CRB’s (criminal record bureau checks). Staff spoken with had a good understanding of adult safeguarding and there was evidence that staff had undertaken adult safeguarding (POVA) training in the staff files examined, Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 19 however no adult safeguarding (POVA) training has taken place in the past year. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 20 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to live in a homely, comfortable and clean environment. EVIDENCE: People’s individual rooms were in a reasonable decorative order and contained many of their personal items. The corridor and toilet in Pines unit has had new flooring and has been redecorated and staff have worked together with some people on decorating their rooms. New items such as a tumble dryer, vacuum cleaner, freezer and stair climbing trolley have been purchased since the last inspection. Specialist beds, hoists and bathing aids have been purchased and staff has received training in their use. The manager said in his annual quality assurance assessment (AQAA) “water regulators are fitted to all hot water outlets and long term and respite are on separate units and there is a door entry code”. A tour of the premises was undertaken and the home was found to be clean and tidy; there was no odorous smells. The manager employs one full time and two part time domestic assistants. People living in the home work Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 21 together with care staff to keep their individual rooms clean and tidy. The manager said in his annual quality assurance assessment (AQAA) “the home is comfortable, well lit, clean and tidy and free from odours. The expert by experience said in his report that the home is clean. People living in the home said that it is always nice and clean and people surveyed said, “the home is always clean and fresh”. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 22 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, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the managers’ recruitment practice can potentially affect outcomes for people living in the home. EVIDENCE: The home has a stable staff team with a low turnover but due to recent longterm staff sickness there has been regular use of agency staff. The manager said that he mainly uses regular agency staff to ensure that there is consistency for people living in the home. In the last three months the home has covered 331 shifts with agency staff. The manager has recently started a new team structure where each staff member is allocated to a unit together with a support team manager; the staff and the manager say that this system is working very well and is supplemented by the use of regular agency staff. The expert by experience said in his report “the home has a key-worker system; members of staff are responsible for making sure that the residents they key work for have things they need like toiletries and other personal items”. Both staff and people living in the home spoken with felt that the key worker role was very effective. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 23 The rotas showed that there was six care staff and a support team manager on each of the two daytime shifts; the night rota showed three staff on duty but did not identify who was awake or asleep. The manager said that during the day when people are at their day services and colleges staff are deployed in other units according to the needs of the people staying in the home. The manager said that the home has not had regular administrative support during the last year but has recently recruited an administrative assistant who has begun the process of updating records. The staff file format was broken down into eight different sections showing 1. Personal details. 2. Identification. 3.Criminal records bureau check. 4.References, qualifications, disciplinary, grievance and incapacity. 5.Application form, job description, person specification, hours and contract. 6.Induction, training and supervision and authenticity of qualifications, personal development and training records. 7.Risk assessments. 8.Sickness record, accident forms and health information. The five staff files examined varied in the level of information contained within them and all but the most recently employed staff contained a completed application form and evidence of induction. Three of the staff files examined did not contain any written references and one no criminal records bureau check; the staff whose check was missing said that a check had been made and that a copy had been provided to the home. Two of the staff files examined contained risk assessments dated 2004 and 2005; there was no evidence that these risk assessments had been reviewed to ensure they were still current. The manager keeps a folder containing the details of agency staff that are employed at the home; the information included a criminal record bureau check number and any training they had attended. There was a variety of training certificates on the staff files examined and these included medication, adult safeguarding (POVA), conflict management, Safe Care and Protection in Essex (SCAPE), Protecting Rights in the Care Environment (PRICE) and The Mental Capacity Act. The manager has prepared a training matrix that shows that staff has received training in the past year in food hygiene, moving and handling, Dysphasia and diversity. The matrix shows that there has been no training in conflict management, challenging behaviour or adult safeguarding since the last inspection. The manager said in his annual quality assurance assessment (AQAA) “staff have worked at the home for a number of years and have continuous training and re training; they are at various level of NVQ training (half the staff) new staff have LDAF (Learning Disability Award Framework); we use regular agency staff and there is a low staff turnover and staff rotate from unit to unit; there is key working and co- key working and there is a record of the training attended”. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 24 The five staff files examined contained evidence of supervision having taken place and four of the staff files contained a supervision agreement. None of the staff files examined contained evidence that the agreed level of supervision had occurred. One staff spoken with said that they had worked at the home for about three years and that their last supervision was in 2006; the same staff confirmed that they are able to speak to the manager informally on a daily basis. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 25 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 adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is stable but shortfalls in the managers quality assurance system and the delayed repairs to the homes electrical system could potentially affect the outcomes for people living there. EVIDENCE: The registered manager has worked in Social care for over fifteen years and has also worked in the health care sector; he has achieved BSc Human Ecology (CNAA), a level 4 Management and a level 5 Executive Diploma in Management and he has attended diversity, manual handling and the Mental Capacity Act training in the past year and he is an NVQ assessor. The manager is in the process of developing the homes quality assurance system; he has prepared an improvement plan for the décor of the home; he holds regular staff and residents meetings. The registered provider makes Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 26 regular visits to the home under Regulation 26 and the reports show that the views of people living in the home are sought; the premises are inspected and its business systems are reviewed. The manager sent people living in the home questionnaires on the quality of his service in November 2006; the views of others such as relatives, nurses, GP’s, social workers or care managers were not included in the 2006 survey and there was no evidence of a report detailing the outcomes. The manager said that no surveys had been undertaken since 2006. The manager returned his Annual Quality Assurance Assessment (AQAA) by the due date and it included all of the required information. The home uses Essex County Council’s health and safety policies and all accidents and incidents were recorded. The manager carried out a fire risk assessment on 31/3/08; fire-fighting equipment was tested in 04/08. The manager said that regular fire drills are carried out at various times (the last one recorded was in 05/08) and all staff and people living in the home have the opportunity to participate in them. Gas safety/heating checks had been carried out in May 2008 and there was evidence that hoists and baths and other equipment was regularly serviced. The manager was unable to locate the homes electrical test certificate at the time of the inspection, however on checking with his electrical contractor the home had an unsatisfactory electrical wiring test in July 2005. The manager obtained a copy of the July 2005 report and it stated, “it is recommended that the electrical system is inspected and tested after a further maximum period of 5 years provided that all category 1, 2 and 3 items are attended to as soon as possible”. The number of defects noted in category 1 was 4, in category 2 was 7, in category 3 was 0 and in category 4 was 25. The manager arranged for an electrical contractor to carry out the work identified in the report on 7th July 2008 and has told us that the work was carried out as planned. Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 27 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 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 15 (2) Requirement The manager must ensure that all care plans are fully completed and that they provide staff with sufficient information on the level of support people require to ensure their needs are met. To minimise the risks to the health and safety of people the manager must ensure that there is a risk management plan in place that is regularly reviewed for all identified risks. To protect people living in the home the manager must make sure that there are protocols in place for as and when prescribed and homely remedies medication and that medication records are fully and correctly completed. To protect people living in the home the manager must ensure that all the required employment checks as detailed in Schedule 2 of the regulations are carried out and the relevant documents are kept on staff files. The manager must improve his quality assurance system to include the views of other interested parties to ensure that DS0000034854.V367883.R01.S.doc Timescale for action 01/09/08 2. YA9 13 (4) (c) 01/09/08 3. YA20 13 (2) 01/09/08 4. YA34 19 (1) (b) (i) 01/09/08 5. YA39 24 01/09/08 Bridgemarsh Version 5.2 Page 29 all views are taken into account. The manager must undertake internal audits of his homes business systems to monitor the quality of his service. 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 YA5 YA12 Good Practice Recommendations To ensure that people living in the home are aware of their terms and conditions it is recommended that each person living in the home have a written contract. To ensure that people living in the home participate in appropriate activities it is recommended that the manager and staff continue to develop a programme of activities both inside the home and out in the local community. To ensure that people know who is on duty it is recommended that the rotas identify who is sleeping in and who is awake during the night. To enable staff to deal with potentially difficult situations it is recommended that the manager provide staff training in risk management, challenging behaviour and updated training in adult safeguarding. To ensure that staff is supported in their role it is recommended that the manager provide them with appropriate supervision. To ensure the safety people living and working in the home the manager should make sure that the homes electrical wiring system is safe and that he holds an up to date certificate. 3. 4. YA33 YA35 5. 6. YA36 YA37 Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Bridgemarsh DS0000034854.V367883.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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