Inspection on 25/05/07 for Bridgemarsh

This inspection was carried out on 25th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bridgemarsh 19/06/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Bridgemarsh 184 Main Road Broomfield Chelmsford Essex CM1 7AJ Lead Inspector Diane Roberts Unannounced Inspection 25th May 2007 09:30 Bridgemarsh DS0000034854.V341588.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.V341588.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.V341588.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.V341588.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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 24th May 2006 3. 4. 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 weekly full fee rate for the home is £1,175:72. Respite placements are needs assessed by social services and rates may vary. 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.V341588.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The registered manager was available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 3 residents and 4 staff were spoken to during the inspection. The CSCI sent feedback/comment sheets to the home for both residents and relatives for completion prior to the inspection. Two have been received from residents and the comments taken into account. Some aspects of this service have failed to improve over the last two CSCI inspections. These are highlighted in the agenda for action. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to consult more with residents and develop quality assurance systems in the home. Residents need to be more involved in their own care planning and a person centred approach should be considered. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 6 The range of activities and education available for residents could be better. Staff training needs to improve. 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.V341588.R01.S.doc Version 5.2 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.V341588.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the team at the home undertake a good assessment, to ensure that residents’ needs will be met, information made available to them could be improved upon to help them make an informed choice, as far as possible. EVIDENCE: Since the last inspection the home has only admitted one permanent resident. It continues to admit service users, on a regular basis, for respite placement. The assessment process was inspected for the new resident. A detailed assessment was found to be in place along with information from the Social Services assessment, giving a good overall picture of the resident, their needs and social situation. The home has completed a good assessment, even though they knew the resident well, from previously providing respite care. Records show that the residents and their family members came to meetings at the home and were able to stay for differing periods of time. Transition periods vary between residents. On meeting a new resident, they had obviously settled in well and were content at the home. The manager undertakes all pre-admission assessments and he goes to all discharge meetings regarding respite placements, to ensure that the home can meet their needs, especially if they are an emergency placement. Consideration Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 9 should be given to updating the assessment documentation so that it has a more person centred approach. Since the last inspection the Statement of Purpose and Service User’s Guide. The content of Statement of Purpose was seen to be satisfactory. The Service Users Guide, whilst containing some useful information, is limited in its value by way of the format. This should be reviewed to ensure it meets the needs of residents’ as far as possible and team needs to evidence that information has been shared. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst aspects of the care planning system are sound, an inconsistent approach, irregular reviews and a limited use of person centred planning affects the overall quality. This both limits resident involvement and can potentially affect positive outcomes for approaches to care. EVIDENCE: The home has a care planning system in place. Care plans from a range of residents were reviewed. The quality of care planning in the home is inconsistent. Some care plans were seen to be more up to date and person centred, whilst others had irregular reviews and limited person centred care plans or information in place. Overall the system was also inconsistent with some residents having different records in place and evidence of resident involvement was not always available. Pertinent information contained on assessment documentation was not always evident within the care planning system. The overall system and person centred care planning was discussed Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 11 with the manager. The manager states in his annual quality assurance assessment submitted to the CSCI that the team needs to work on reviewing care plans, reflecting the needs and wishes of residents and developing a more pictorial system. It was disappointing to note that residents who were able to communicate their preferences had limited evidence of this in their care plan, although from observation and on discussion with staff, they are very keyed up to resident’s individual needs and feelings, very sensitive to what they like and dislike and how they communicate. On touring the home it was observed and heard that residents are treated respectfully, asked questions and their responses accepted. One care plan was noted to contain a dvd, which contained a residents’ record of photos of favourite places, choices, significant people and family. This was seen to be a good way of involving residents as it could be watched with staff and providing a more person centred approach. The manager plans to use more IT resources in the care planning system in the future. The home cares for residents who visit regularly on a respite basis. Care records show that functional assessments had been completed, but were not dated. Although this assessment contained relevant information it did not link into the care planning system. No risk assessments were on file and no reviews were evident even though the resident visited regularly and notes were on file from 1998. The care plans in place were seen to be very basic and noted only a few personal preferences. From records and discussion, residents are helped with decision-making processes by both the care management team and via advocacy services. Three residents are currently accessing advocates. Where possible, work is being done to help residents access community housing and lead an independent lifestyle but unfortunately this is often limited due to varying factors out of the team’s control. Whilst residents are encouraged to manage their own finances, dependency levels affect the level of involvement. The home holds money on behalf of all of the permanent residents, with respite residents retaining their own and using safe keeping facilities in their rooms. Staff have good management systems in place and spend a significant amount of time checking amounts and getting money ready for residents to take out with them on a daily basis. The home uses a range of risk assessments contained within the care planning system. Whilst containing detailed information, these were not always up to date and a more systematic approach may make them a more useful tool. It was also noted that one resident had identified risks that had no risk assessment in place. Risk assessments do evidence that residents are accessing the local community in a variety of ways, some with more support than others. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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. Residents are able to access a range of activities primarily linked to social service provision. Further person centred work on aspects of resident’s daily lives may enable them to have a wider choice and access community groups in a more meaningful way. EVIDENCE: From records and discussion, residents are able to access educational activities via a range of local, mainly social service run, resource centres. The team at the home facilitates some of these and relatives facilitate others. Activities include computer skills, literacy, numeracy and arts and crafts. On discussion, the manager is keen that residents have choice and where possible he would like the resident to be able to choose the centre he/she wished to attend. Some residents at the home attend college and others work at a local recycling centre on a voluntary basis. At the time of the inspection, no residents are Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 13 accessing paid work in the community. The manager states in his annual quality assurance assessment, submitted to the CSCI, that the team need to work on re-enforcing the skills that residents learn at their day and educational centres to enhance their potential in providing for their own daily living tasks. Residents access the local community primarily for leisure activities such as bowling, shopping, the cinema and walks etc. Both staffing levels and access to transport can limit this at times, as the majority of the residents need significant levels of support. The home relies heavily on the fact that the League of Friends supplies a minibus with a tail lift and without this staff feel that residents would be further limited. Some residents have funding arrangements that allow for an increase staffing compliment to enable them to go out of the home with staff on a one to one basis. When asked for feedback, as part of the homes own quality assurance programme, staff at the home felt that more activities could be provided during the day and in the evenings and that residents do not go out much. The manager states in his annual quality assurance assessment that more activities and social outings need to be arranged for residents. The home has an open visiting policy and on the day of the inspection it was possible to speak to relatives visiting the home, who were positive regarding the services and facilities offered. Some residents do go home and visit their families and where able go on holiday to a variety of places including France. Access to community groups that are not linked to services for people with learning disabilities are not currently in use and this should be explored further. From observation and discussion, the staff and the resident team get on well and interaction between them was seen and heard to be relaxed and respectful with staff taking small opportunities to promote independence and self worth amongst individual residents. Residents’ who commented said that the staff treated them well. During the day of the inspection, residents were observed to have choice in how they were spending their day and records also evidenced this to an extent, including when residents had chosen not to attend a day centre. Records within the care planning system could improve to reflect this more and show that there had been consultation with the resident on this aspect of their lives. Meals in the home are prepared in the main kitchen and it was possible to talk to the chef on the day of the inspection. Whilst the manager would be happy to look at the provision of meals with the unit setting, resident dependency, appreciation of risk and facilities do not allow for this at the current time. Occasional some informal breakfast cooking takes place and residents are involved where possible. One resident said that ‘I can choose my own breakfast’. The meal service was reviewed and founds to be varied and nutritionally sound. Breakfast contained a good range of choice, including healthy options. Many of the residents take a packed lunch out with them and Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 14 the chef is aware of individual preferences regarding this. The chef always makes home made soups and also does a lot of home baking and prides herself on providing as little processed food as possible. The majority of residents have a main meal in the evening. Some residents are on special diets and peg feeding which are appropriately managed. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs are generally met but improvements could be made to ensure positive outcomes for residents. EVIDENCE: Care plans need to be developed in a more person centred way, to ensure that where residents are able to express their wishes regarding personal care support, all staff know these wishes. Whilst there is some good information there is not a consistent approach. This is especially important as the home is using regular agency staff. The home uses a key worker system but this was not evident from the care planning records. Overall records show that residents’ healthcare needs are met in a proactive way, with timely visits from general practice staff. Records could improve to reflect the visits/advice in more detail and then be reflected in the appropriate care plan. Staff have been trained to deal with any specialist devices, such as peg feeds and records of monitoring show that staff do this efficiently. Records show that residents are referred to specialists, as appropriate, such as dieticians and speech therapists. Records show that residents’ weights are not Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 16 regularly monitored and this could improve as it was noted that residents who may benefit from proactive care planning to improve their overall health had not been weighed. The manager states in his annual quality assurance assessment that they need to improve on this aspect of residents care. Where required specialist beds and pressure relieving devices were in place. The home uses a monitored dosage system of medication supplied by a local pharmacy. Staff report that the visiting GP’s to the home know the residents well and medication reviews are carried out by them and specialist consultants. The system and records were inspected and found to be generally in good order but the staff team need to pay more attention to signing and checking in prescriptions arriving during the months, having dates of opening on liquids for audit purposes and old medications should be returned to the pharmacy more regularly. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to help ensure that residents will be listened to and their rights protected. EVIDENCE: The home has a satisfactory complaints procedure in place. This is also available in a pictorial format. Residents who commented said that they knew who to raise any concerns with. Since the last inspection the home has received five complaints. These were seen to have been logged and appropriate records maintained. The manager has an open and objective approach to complaints and responses to complainants were well managed. Complaints related to the home’s facilities and odour control, laundry management and building security and an issue between two residents. One complaint was out of the manager’s span of control and related to Essex County Council policy regarding respite care. The home has satisfactory adult protection procedures in place. Training records submitted to the CSCI show that the majority of staff have attended training on adult protection and twelve staff out of thirty seven have had training over the years on risk and conflict management. There are some staff working in the home who have not received POVA training and this should be addressed. Whilst the manager does report incidences to CSCI these should be dealt with in a timelier manner and final outcomes also notified to the CSCI. At the time of the inspection the manager was dealing with two adult protection issues and a denial of rights issue. These were seen to be being Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 18 dealt with appropriately and the correct interested parties had been informed/involved. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards of decoration in the home are satisfactory but systems need to be in place to ensure that risk assessments and safety certification are kept up to date in order to promote health and safety in the home. EVIDENCE: A partial tour of the home was undertaken. Overall the home was clean. An odour was noted in one of the respite bedrooms and this has lead to two complaints since the last inspection. This has yet to be addressed, as the manager tends to use the budget on permanent residents rooms rather than the identified respite rooms. The proprietors should address this sort of limitation on the budget in order to improve outcomes for all residents spending time at the home. Residents’ bedrooms were in good decorative order and many of them had been personalised by the resident. Some bedrooms have had new carpet fitted and some hallways have also had new Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 20 flooring. Overall décor and furnishings were seen to be of a satisfactory standard. Where required specialist beds, lifting equipment and adaptations have been made to help ensure that residents’ needs can be met. Records show that with regard to lifting specific slings etc. have been purchased for specific residents. Specialist bathrooms are also available. A new call bell system is currently being installed which should be of benefit to both the residents and the staff. A new patio has been laid to the rear of the home, since the last inspection and this provides a pleasant seating and barbecue area. The local league of Friends actively supports the home and has paid for a new large barbecue for the home. It was noted that although residents have access to a computer in one of the communal areas, they do not have access to the internet. Maintenance and safety certificates were inspected at random. The gas safety certificate was seen to be in order. The safety certification for the wiring of the home was not available. This needs to be addressed. A fire safety risk assessment was completed in 2005. This needs reviewing and the local fire officer has also raised this. The Fire officer also feels that the assessment is not comprehensive enough and that the home’s fire training is not sufficient. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are significant shortfalls in relation to staffing, primarily agency use and training, that could adversely affect the quality of services provided to residents. EVIDENCE: The staff team at the home is stable and turnover is low. This is positive for the resident group. The home does however have vacant hours, which the manager has not been able to recruit to due to the provider’s current policy. The home also has staff on long term sick leave and therefore agency staff are in use at the home. In the last three months 548 hours of agency staff have been used. Since the last inspection the staffing levels at the home have been reviewed and increased both during the day and at night in one unit to ensure that residents rights are not infringed. The current staffing levels are as follows: Am – One team manager and 6 care staff Pm – One team manager and 6 care staff Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 22 Night – One manager and one awake and one asleep plus one extra awake for specific duties on one unit. The manager works in a supernumerary capacity usually during the hours of 9.5 pm. The annual quality assurance assessment submitted to the CSCI shows that over 50 of the staff team have achieved NVQ level 2 and above and further staff are undertaking this qualification. Eleven staff have also completed SCAPE training in the past. Some staff have received training in other additional subjects such as diabetes management, dementia, epilepsy management including administration of medication, peg feeding, Further training records submitted along with the homes quality assurance reports show that there are significant shortfalls in relation to fire safety, first aid, manual handling, some food hygiene and as previously stated adult protection. No staff have had training in infection control and there are significant shortfalls in training regarding managing challenging behaviour. This needs to be addressed in order to provide a quality service in the home. The manager is planning staff training in equality and diversity via workbooks this year. Recruitment practices at the home remain sound and no staff have been recruited since the last inspection. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Management at the home is stable but time needs to be spent on developing quality assurance systems so that the home develops with residents and other interested parties comments in mind. EVIDENCE: The manager has an open and objective management style. Staff spoken to speak positively about him and feel that he is supportive and that his communication is good. Records show that regular visits are undertaken by the responsible individual and involve the manager. Reports of these, show that residents’ views are sort and the premises and business systems are reviewed. The manager has been consulting with the staff team on aspects of running the home and resident care. This is a good consultation but the Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 24 manager has yet to progress this further into completing any action points raised. The manager feels restricted by the current reorganisation within social services. Quality assurance systems in the home are basic. The manager has some appreciation of quality assurance systems but this needs to be developed. Resident meetings have not been taking place and there are no formal systems for obtaining their feedback other than visits by the responsible individual. Feedback from staff, as discussed above, was seen to be positive. No feedback is currently sort from relatives or other interested parties and there is no internal audit of business and recording systems. The home has a health and safety policy in place. Accident records were reviewed and seen to have been completed well. There are more incidences in the home rather than accidents and this should be considered when planning staff training in relation to dealing with challenging behaviour. The manager does have a logging system for accidents/incidents and should be analysing these but records were seen to be three months behind. Bridgemarsh DS0000034854.V341588.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 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 X 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 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 1 X X 3 X Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 26 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12 and 15 Requirement Where possible care plans must involve the resident and regular reviews must take place. Care plans must be in place for all identified needs and must include residents’ personal choices and preferences. Risk assessments must be in place for all identified risks and they must be kept under review to ensure that risks are kept at a minimum. The staff team should develop more opportunities for residents with regard to activities during the day, evening and weekends, including getting out of the home more to improve the quality of life for residents. Residents weight should be monitored where possible to ensure that their healthcare needs are being fully met. The home must have an up to date certificate for the wiring of the premises Odour management must improve in respite bedrooms. The management of the home must try to reduce the amount DS0000034854.V341588.R01.S.doc Timescale for action 30/09/07 2. YA7 12 31/07/07 3. YA13 16 30/09/07 4. YA19 12 31/07/07 5. 6 7. YA24 YA30 YA32 23 16 18 31/07/07 31/07/07 30/08/07 Bridgemarsh Version 5.2 Page 27 8. YA34 18 9. YA39 24 of agency staff in the home to improve the quality of care provided to residents. Staff training needs to improve in order to ensure positive outcomes for residents. This relates to fire safety, food hygiene, first aid, manual handling, adult protection, managing challenging behaviour and infection control. 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 timescales set of the 31/12/05 and the 31/08/06 were not met in full. This is a repeat requirement. 30/09/07 31/08/07 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 3 4 5 Refer to Standard YA1 YA20 YA12 YA23 YA24 Good Practice Recommendations Consideration should be giving to providing a service users guide in a more appropriate format for the resident group. Staff should ensure that the management of medications at the home improves. The staff team should develop more opportunities for residents with regard to education and work experience to ensure their potential is maximised. The manager should have a more efficient system in place for notifying the CSCI of POVA referrals under Regulation 37. The fire safety risk assessment should be reviewed regularly and the content reassessed after comments from the fire officer. Bridgemarsh DS0000034854.V341588.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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.V341588.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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