Inspection on 03/05/05 for Bridgemarsh

This inspection was carried out on 3rd May 2005.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bridgemarsh 19/06/08

Bridgemarsh 25/05/07

Bridgemarsh 24/05/06

Bridgemarsh 04/10/05

Bridgemarsh 08/09/04

Bridgemarsh 06/05/04

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Paradise Lodge

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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 Draft Unannounced 3rd May 2005 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 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 Stationary 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 I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Essex County Council Vacant Care Home 28 Category(ies) of (LD) Learning Disability (28) registration, with number (LD(E)) Learning Disability over 65 years (1) of places ((PD) Physical Disability (6) Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 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 3 4 Date of last inspection 08/09/04 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 range from being low to high. The home provides a range of shared facilities both inside and outside the home for use by service users. The home is on a bus route that serves the centre of town, shops, recreational and public services. The home also has access to community transport facilities, but has recently lost access to a vehicle previously provided. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over one day in May 2005, lasting approximately 6.00 hours. The inspection process included: discussion with the acting manager, five members of staff and three service users; premises observation of three bedrooms, a bathroom, and communal areas and gardens; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty of the forty-three standards were inspected; of these fifteen were met, four were partially met and one was a major shortfall, resulting in five requirements, three of which are repeat requirements. What the service does well: What has improved since the last inspection? Since commencement in post the acting manager has worked extremely hard at streamlining the care provided by the home. Significant work is in hand to further develop service users’ care plans within a person-centred framework. The home’s supervision process is good, with staff receiving formal supervision monthly and group supervision bi-monthly. In addition, staff have access to informal supervision on a daily basis. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 6 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 I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 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 standard(s) 2 and 3. The care plans sampled and pre-admission assessments used by the home indicated that individuals needs and aspirations are identified. The home and staff are well equipped to meet the needs and aspirations of the service users. EVIDENCE: Service users admitted to the home are referred by care managers and are accepted only if accompanied by a Community Care Assessment. In addition, the home visits all prospective service users and completes their own in-house pre-admission assessment. Through discussion with the acting manager and observation of staff interactions with service users during the period of the inspection, it was apparent that staff have the necessary skills to support service users to meet their needs and aspirations. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 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 standard(s) 6. Care plans sampled were comprehensively presented. EVIDENCE: The care plan sampled was comprehensive in the level of detail provided. In addition, the home is in the process of further developing its care planning format to ensure service users’ involvement in all areas of their care planning. This new approach will further enhance the home’s care planning process. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13,14,15,16, and 17. The home positively supports service users to engage in purposeful leisure activities and maintain family links, and works hard to ensure that service users rights are respected and upheld. EVIDENCE: Service users spoken with during the course of the inspection spoke of accessing a range of community based activities. One service user spoke of visiting town regularly, sometimes with support, and on others without. Another service user spoken with spoke of attending the local college, where they attended classes in numeracy and literacy. Discussion with service users and staff evidenced that service users are supported positively to engage in their interests and hobbies. A service user spoken to spoke of being supported to maintain links with their family by telephone calls and the writing of letters. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 11 Staff spoke of the home having an open door policy on the receiving of visitors and of service users being free to decide where they wished to receive their visitors. During the course of the inspection service users were witnessed to have keys to their rooms. Staff were seen and heard interacting with service users and not exclusively with each other. A service user spoken with spoke of their choice in relation to their right to opt in or out of activities. Service users spoke of meals provided being nice and of choices being available. Meals are prepared in the main kitchen, although all units have small kitchen areas that are equipped to enable them to prepare snacks. Dinning areas were pleasant and gave the impression of creating a relaxed setting in which service users would be able to enjoy their meals. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19 and 21. Service users healthcare needs are well met, with documentary evidence being well maintained. Records relating to ageing, illness and death continue to require some further development. EVIDENCE: Discussion with the acting manager indicated that liaison is now taking place with service users’ community nurses to develop health action plans. In addition, personal health records are being developed for each service user. All service users are registered with a General Practitioner. The acting manager presented a new care plan format which included extensive records for the recording of service users’ healthcare needs. Whilst some work has been undertaken in terms of identifying the wishes of service users and/or their relatives in the event of the service users’ demise, the acting manager spoke of their intention to raise this issue again during the service users’ annual reviews, to ensure that all parties were on board, and in agreement with the process undertaken. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 22 and 23. The homes Complaint, Whistle Blowing and Adult Protection policies were robust in terms of protecting service users from harm or abuse. EVIDENCE: The home’s Complaint Procedure/Policy is comprehensively detailed and is available in pictorial format for ease of use by service users. The home’s Adult Protection and Whistle Blowing policies were robust and adequate to ensure that service users are kept safe from harm or abuse. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 26 and 27. For the majority of service users the home provides rooms that are pleasantly decorated, however on the day of the inspection this was not the case for all. For the majority of service users the home provides bathrooms that are adequate to meet the needs of service users, however this was not the case for all. EVIDENCE: During a tour of the premises a service user’s bedroom was seen to be in need of some basic redecoration. The service user themselves spoke of their wish for their room to be redecorated. A concern was raised at the previous inspection in relation to a service user whose bathing needs were needing to be met in another unit, due to the inability of their own home to meet their needs. This issue has now been priced up and a budgetary allocation approved. In the meantime, the service user in question continues to access the facilities in the other unit. This matter requires addressing as a matter of urgency. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 36. The homes recruitment procedures are generally sound, although on the day of the inspection one of the files sampled contained some omissions. Staff are supported by a thorough supervision process. EVIDENCE: Three staff files were sampled in terms of the home’s recruitment practices. A number of omissions were noted in relation to Schedule 2 of the Care Homes Regulations. These were discussed with the acting manager at the time of the inspection. The acting manager was referred to schedule 2 for further guidance. Discussion with the acting manager indicated that staff receive formal supervision monthly, with group supervision taking place bi-monthly. Staff also spoke of having access to managers on a daily basis for informal supervision. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38 and 39. Staff are supported by an experienced manager, who is open and accessible at all times. The home benefits from a quality assurance process which the manager wishes to develop further. EVIDENCE: The acting manager is qualified at N.V.Q level 4 in management, and has extensive experience of working in a care setting. Staff spoken with during the course of the inspection spoke of the manager’s openness and accessibility. The home’s quality assurance process is currently dealt with corporately, although the manager spoke of wishing to develop their own in-house process. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x 2 1 x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bridgemarsh Score x 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x x x I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 18 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 YA 21 Regulation 12 (3) Requirement The responsible person must make provision for recording the wishes of service users, in the event of their demise. This is a repeat requirement The responsible person must ensure that the home is kept in a reasonable state of decor The responsible person must ensure that appropriate bathing facilities are available to meet the needs of service users. This is a repeat requirement The responsible person must ensure that documents regarding staff recruitment are maintained as per schedule 2 of the Care Homes Regulations. This is a repeat requiremnet The responsible person must establish and maintain a system for reviewing and improving the quality of care provided This is a repeat requirement Timescale for action End of August 2005 End of August 2005. End of August 2005 End of August 2005 2. 3. YA26 YA27 23 (d) 23 4. YA34 19 (Schedule 2) 5. YA39 24 End of August 2005. Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 19 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 Good Practice Recommendations Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 1st Floor, Fairfax House Causton Road Colchester 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. Extracts may not be used or reproduced without the express permission of CSCI Bridgemarsh I56-I05 S34854 Bridgemarsh V220313 030505 Stage 4.doc Version 1.30 Page 21 - 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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