Inspection on 24/05/06 for Bridgemarsh

This inspection was carried out on 24th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. 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 19/06/08

Bridgemarsh 25/05/07

Bridgemarsh 04/10/05

Bridgemarsh 03/05/05

Bridgemarsh 08/09/04

Bridgemarsh 06/05/04

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Claremont House

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Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

15 Bramble Close

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

CARE HOME ADULTS 18-65 Bridgemarsh 184 Main Road Broomfield Chelmsford Essex CM1 7AJ Lead Inspector Neal Cranmer Key Unannounced Inspection 24th May 2006 09:10 Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 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.V290118.R01.S.doc Version 5.1 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.V290118.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bridgemarsh Address 184 Main Road Broomfield Chelmsford Essex CM1 7AJ 01245 440858 01245 442239 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) www.essexcc.gov.uk Essex County Council 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.V290118.R01.S.doc Version 5.1 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 4th October 2005 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. Service users’ support needs vary from being low to high dependency. The home provides a range of shared facilities both inside and outside the home for use by service users. The pre-inspection questionnaire submitted on the 9th May 2006 stated that the weekly full fee rate for the home was £1,084:51. The only additional charges are made for: • • • • • • Hairdressing Toiletries Magazines/newspapers Holidays, day trips, eating out Clothing Transport and chiropody. 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. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection to Bridgemarsh, which took place on 24th May 2006, the first inspection at the home for the year 2006/2007. The registered manager was available throughout the course of the inspection. The fieldwork visit to the home was carried out between the hours of 09:10 and 15:45. This inspection included discussions with the registered manager, service users, an advocate and staff. In addition a range of documentary records and files were sampled. A total of twenty-one standards were inspected, of which fifteen were met, the remainder being minor shortfalls. A tour of the premises was undertaken which evidenced that they were well decorated and maintained. The premises were equipped so as to meet the needs of the service users in residence. What the service does well: What has improved since the last inspection? Since the previous inspection the home has improved its risk assessment process. The home’s complaints procedure has been improved upon and now meets with regulatory requirements. Evidence was provided that indicated that all Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 6 staff have now either received or are in the process of receiving training in adult protection. The service has addressed the areas of the environment where at the previous inspection the floor coverings were noted to be badly stained. Since the previous inspection records kept at the home relating to staff recruitment have been improved upon, and those seen now meet with regulatory requirements. Staff supervision at the home has been much improved; staff reported that they now receive formal supervision every six to eight weeks. Staff spoken to during the course of the inspection stated access to staff training was good. The home supports service users to access advocacy services as and when required. 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. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 7 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.V290118.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users and/or their representatives are provided with most of the necessary information required to enable them to make a choice about the home’s ability to meet their needs. Service users’ needs and aspirations are assessed prior to them being admitted to the home. EVIDENCE: The home’s Statement of Purpose continues to require updating and reviewing to ensure that the information within it is current to support potential service users with all of the required information to enable them to make an informed choice about entering the home. Three service users’ files were sampled during the course of the inspection. Of these three two contained evidence of a full needs assessment having been carried out, the third contained an assessment of need carried out by a care manager. Each assessment seen was comprehensively detailed and had been used to inform the content of the service user’s care plan. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ assessed and changing needs are reflected in their individual plans of care. Service users are supported to make decisions about their every day lives, with support as required. Service users are supported to take risks as a part of developing an independent lifestyle. EVIDENCE: Service users’ care plans are generated from an assessment of needs, either carried out by the home or through the care management process. Where possible, plans are drawn up with the involvement of the service users. The three plans sampled evidenced that all bar one had been reviewed. Each service user has a dedicated key worker. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 10 Discussion with one service user during the course of the inspection evidenced that they had accessed an independent advocate who was heavily involved with supporting them in moving into more independent living. The service user had been supported to develop their own life plan and to develop computer skills. This had been honed to a high level and the service user spoke of using this skill to ensure their wishes were communicated. Discussion with the registered manager indicated the intention to develop this process further to make it available to service users who are less able. Service users are encouraged to manage their own financial affairs. Care plans sampled evidenced that service users are supported to take risks as part of developing a more independent life style; service users spoke of accessing the local community independently. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users are supported to access opportunities and take part in activities that are age and peer appropriate. Opportunities for service users to access and take part in meaningful community based activities are limited. Service users are supported to maintain links with families and friends. The daily routines of the home are such that they promote independence, individual choice and freedom of movement. Service users are provided with a healthy and wholesome diet. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 12 EVIDENCE: Discussion with staff indicated that opportunities for service users to take part in educational activities are addressed through attendance at the local resource centre which service users left to attend on the day of the inspection. One service user spoken with was keen to show their skills on the computer. Discussion with staff indicated that opportunities for service users to take part in meaningful activities within the community are limited. This was largely, they felt, impeded by staffing levels, which although adequate to meet basic needs of service users, did not allow for individual community access. The home has an open door policy on the receiving of visitors, and families and friends are made welcome. Service users are at liberty to choose where they receive their visitors. The daily routines of the home promote independence. Service users were seen going about their own business in a variety of ways, sitting in communal lounge watching TV together, chatting, playing an electric organ and working on a computer. Service users were seen to have access to all areas of the home and its grounds, only restricted by limited access to other units on the site without invitation. Staff were seen and heard interacting with service users positively, always referring to them by their preferred terms of address; the rapport seen between service users and staff was good. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ physical healthcare and emotional needs are catered for well. EVIDENCE: All service users are registered with a General Practitioner and service users are supported to access a range of locality based healthcare services. Sampling of care plan folders evidenced that service users’ healthcare records are well maintained. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has in place a clear and effective Complaints Procedure designed to ensure that service users’ views are listened to and acted upon. The home’s Adult Protection policies and procedures are robust and protect service users from the risk of harm and/or abuse. EVIDENCE: Since the previous inspection the home’s complaints procedure has been reviewed and now meets with regulatory requirements. At the previous inspection it was highlighted that a number of staff had not received training in adult protection, the majority of staff have now received the training. Evidence was seen of further sessions planned for those remaining staff who had not yet attended. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ bedrooms are equipped with the necessary furniture and fittings to meet individual needs and lifestyles. The home is equipped with a wide range of environmental aids and adaptations that enable the needs of service users to be met. The home environment is kept clean, and on the day of the inspection was free from any offensive odours. EVIDENCE: Service users’ bedrooms visited were well equipped with the necessary furnishings and fittings. Service users have personal items in their rooms and one service user spoke of having been involved in choosing of the colours of their room. Service users are able to lock their rooms, although this can be over ridden by staff in the event of an emergency. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 16 The home is equipped with a range of environmental aids and adaptations designed to maximise service users’ independence. These included: • • • • • Overhead tracking Specialist baths Hand grab rails Specialist shower trolleys Emergency pull cords. Each of the five units has its own laundry facility, which was domestic in nature; all were situated well away from areas where food preparation takes place. All were equipped with hand washing facilities. On the day of the inspection all areas of the home visited were clean and hygienic and free from any foul or unpleasant odours. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 36. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are supported by an effective staff team, however staff numbers are inadequate to fully meet the needs of service users. Service users are well supported by the home’s recruitment practices. Service users benefit by being supported by a team of staff who are well supervised. EVIDENCE: Service users are supported by a team of staff who are experienced and competent. Discussion with the registered manager and staff indicated that the needs of service users had changed significantly in recent months which led to the view that the staffing levels, particularly at night, were no longer adequate or safe. The staffing levels were as follows: A.M Community support facilitators x5, in addition one Support team manager, and registered manager (working in a supernumerary capacity, 9-5) P.M Community support facilitator’s x5, in addition one Support team manager. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 18 Nights are currently covered by two waking night staff and one sleep-in staff, one of the two waking night staff has to remain on one unit due to the complex needs of the service users. This leaves the remaining one waking night staff available to meet the needs of up to twenty service users, some of whom it was reported require assistance with manual handling issues. The manager voiced a significant concern in respect of potential risks to both service users and staff. The inspector directed that an urgent review of the staffing levels at the home be undertaken. In the interim the manager has already started to collect and collate information provided by night staff in relation to the frequency/duration of time that sleep-in staff are called upon to support waking night staff. Staff files sampled in respect of the home’s recruitment practices were well maintained and no concerns exist in respect to the home’s recruitment practice. Discussion with both the registered manager and staff indicated that formal supervision is now taking place every six to eight weeks. Staff supervision files have been set up for each member of staff, each of which was seen to contain a supervision contract between the supervisor and the supervisee. Staff spoke of team meetings taking place monthly, although the minutes of these were inconsistent. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 41. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by a team of staff who are managed by a manager who is competent and experienced. The home’s quality assurance process requires further development to ensure that it adequately reflects the views of service users. Records required to be kept under regulation require further development. EVIDENCE: The registered manager is competent and has significant previous experience to run the care home. Discussion with staff evidenced that the manager provides a clear sense of leadership and direction, and there was a sense that the home was managed and run in an open and transparent style. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 20 Staff indicated that team meeting are held monthly, although records to support this statement were inconsistently maintained. Discussion with the registered manager evidenced that there is no formal process in place for reviewing and keeping under review the quality of the home’s service provision. The home has commenced open coffee mornings as a means to obtaining the views of the service and how it maybe improved, and is open to residents’ families. A questionnaire has been developed for the purpose of sharing at the coffee morning for comments to be made. The organisation provides Regulation 26 reports to the CSCI on a monthly basis as required. Some gaps were noted in the service users’ files sampled, with reference to the records that are required to be maintained under Regulation 17, schedule 4 of the Care Homes Regulations, these included: • • • Copies of Statement of Purpose and Service Users Guide One file did not contain a needs assessment One did not contain a service users plan, daily records or subsequently any evidence of review. The responsible person needs to ensure that all of the records specified under Schedule 4 are maintained in respect of each and every service user. Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X X 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 x 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 3 2 X 2 X X Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 22 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 YA1 Regulation 6 Requirement The responsible person must ensure that the home’s Statement of Purpose is kept under review and is current in terms of the information contained within it. The previous timescale set of the 31/12/05 was not met. The responsible person must not admit to the home any service user without first having acquired a full needs assessment in respect of the person. The responsible person must having regard to the size of the care home ensure that at all times suitably competent and experienced persons are working in such numbers as are appropriate for the health and welfare of service users. This relates specifically to the need to review staffing levels, particularly in relation to night cover. Timescale for action 31/08/06 2. YA2 14 31/08/06 3. YA33 18 (1a) 31/08/06 Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 23 4. YA41 17 The responsible person must ensure that records specified under Schedule 4 of the Care Homes Regulations are maintained in respect of each service user. The registered person must provide evidence that the home has in place a system for reviewing and keeping under review the quality of its service provision. The previous timescale set of the 31/12/05 was not met. 31/08/06 5. YA39 24 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA13Y Good Practice Recommendations It is recommended that further consideration be given to ways in which opportunities for service users to take part in educational/occupational activities can be further developed. It is recommended that the care plan files be laid out in a fashion that make them more accessible and user-friendly, and generally easier to track through. 2. YA6 Bridgemarsh DS0000034854.V290118.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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