Inspection on 04/10/05 for Bridgemarsh

This inspection was carried out on 4th October 2005.

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 25/05/07

Bridgemarsh 24/05/06

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 Neal Cranmer Unannounced Inspection 4th October 2005 09:30 Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 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.V255569.R01.S.doc Version 5.0 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.V255569.R01.S.doc Version 5.0 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) 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.V255569.R01.S.doc Version 5.0 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 3rd May 2005 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 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.V255569.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over one day in October 2005, lasting 6.25 hours. The inspection process included: discussion with the duty officer, three members of staff and two service users; premises’ observations of three service users bedrooms, two bathrooms, communal and garden areas; and inspection of a sample of policies and records. Fifteen of the forty-three standards were inspected, of which five were meet, eight were partially meet, with the remainder being major shortfalls. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that risk assessments are carried out in respect of all service users, and that these are based upon the service users’ assessed needs. The home needs to ensure that its Complaints Procedure complies with regulatory requirements. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 6 The home must ensure that all staff are trained in adult protection matters to ensure that service users are protected from the risk of suffering harm or abuse. The registered person must ensure that all areas of the home are kept in a clean and reasonable state of repair. The registered person must ensure that all documentation required by regulation is kept in respect of staff employed at the home, and ensure that they receive the appropriate level of supervision necessary for them to carry out their roles effectively. The registered person must ensure that a mechanism is in place for keeping the quality of the home’s service provision under review. 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.V255569.R01.S.doc Version 5.0 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.V255569.R01.S.doc Version 5.0 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. The home’s Statement of Purpose and Service Users Guide were both deemed to contain the necessary information to enable service users to make an informed choice about where to live, although both required reviewing to ensure that they contained up to date information. EVIDENCE: The home’s Statement of Purpose was sampled and was seen to be in need of reviewing to include the correct details relating to the registered manager. The Service Users Guide was also seen to be in need of reviewing to include the current details of the registered manager. In all other respects both documents were deemed to be in compliance. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 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): 9. The home needs to further develop its process of risk assessing service users’ needs. EVIDENCE: The support plan of a service user who had been admitted to the home on a probationary period was sampled. No record was seen of any risk assessment having been carried out. A further two plans were sampled which contained some evidence of risk assessment activity having been undertaken. However, the home needs to develop these further to ensure that risk assessments are carried out for all service users based upon service users’ assessed needs. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 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 the following standard(s): No outcomes for this section were inspected on this occasion. EVIDENCE: Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 11 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): 18 and 20. Service users’ personal support was seen to be appropriately provided. The home’s medication procedures were deemed to be safe at the time of the inspection. EVIDENCE: During the course of the inspection service users were seen to be supported sensitively and in a manner that respected service users’ privacy and dignity. Personal support was witnessed in one of the houses visited to be provided in private. There was evidence of technical aids and equipment being available to enable service users to maximise their independence. The medication process in one house was sampled and seen to be in order. The home now operates a dual signatory system following a recent medication concern at the home. Medication is dispensed by staff following completion of the Essex County Council’s medication workbook. The staff-training folder evidenced that to date nineteen staff have completed the training. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 12 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. The home’s Complaints Procedure requires some further work to fully comply with requirements. The registered person needs to ensure that all staff working with vulnerable people receive training in this area to ensure that the risk of harm or abuse to service users is kept to a minimum. EVIDENCE: The home’s Complaints Procedure was sampled and found to require some additional work to comply with national Minimum standard 22. The manager is referred to the subsections of Standard 22 for further guidance. The home follows the Essex County Council’s Guidelines on Protecting Vulnerable Adults; the procedures were seen to be robust and were linked to the Public Disclosure Act of 1998. In-house guidelines for staff to follow when dealing with allegations of abuse were seen to be in place. Evidence was presented that indicated that eleven staff out of a team of approximately thirty have received training in the area of protection. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 13 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): 24, 26, 27, and 30. The home provides a homely, comfortable and safe environment for service users. Service users’ bedrooms visited were seen to be equipped with the necessary furnishings and fittings to meet their individual needs and lifestyles. Some concerns continue in respect of the home’s ability to currently provide bathing facilities that meet service users’ needs, however these concerns have been taken on board and are scheduled to be addressed. On the day of the inspection all units visited were found to be clean and tidy and were free of any unpleasant odours. EVIDENCE: The home was deemed to be fit for its stated purpose, being accessible, safe and generally well maintained. Furnishings and fittings were of a reasonable quality and were domestic in nature. The premises on the day of the inspection were found to be bright and cheery, and there was no evidence of any unpleasant odours. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 14 A number of service users’ bedrooms were visited which were seen to be fitted with the necessary furniture and fittings to support service users’ individual needs and lifestyles. A number of bedrooms visited in the special care unit were seen to be equipped with Hi-Lo beds. A number of carpets in personal and communal rooms were noted to be badly stained. Bedding and curtaining were seen to generally to be in good condition. In a number of the rooms allocated for respite care there was little evidence of any attempt to create a homely feel. The issue identified at the previous inspection of a service user needing to leave their home to have their hygiene needs meet in another house continues due to the inability of the bathing arrangements in their own house being unable to meet their needs. The work necessary to address this matter has been agreed and funded, and was reported to be taking place in November 2005. Each of the five units has its own domestic style laundry facility, one has a sluicing facility, with a second being fitted with a washing machine with a sluicing facility. All were situated well away from food preparation areas. One sluice room visited was seen to be doubling as a storage space which could pose a risk to health and safety. All laundry rooms had hand-washing facilities available. On the day of the inspection all the units visited did not have any unpleasant odours about them. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 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 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): 34, 35 and 36. The home’s recruitment practices continue to require further development to comply with regulatory requirements. Evidence would suggest that staff are well trained and that access to staff training is good. The home’s formal supervision process needs to be reviewed to ensure that staff receive the necessary formal supervision to enable them to carry out their roles effectively and competently. EVIDENCE: Three staff files were sampled in respect of the home’s recruitment practices. Whilst it was noted that the files are under going full review to ensure compliance with regulations, it was still evident that a number of shortfalls continue in respect of requirements. The registered manager’s attention is drawn to Schedule 2 of the Care Homes Regulations for further guidance as to the documentary evidence required to be held on file in respect of staff employed at the home. Discussion with staff indicated that access to training was generally good. The home maintains a file of staff training. Records sampled contained evidence of training in the following areas: Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 16 • • • • • • • • • • • • N.V.Q Level 3 LDAF (Learning Disabilities Award Framework) Conflict management S.C.A.P.E training Manual handling Medication administration Food hygiene Training in diabetes Dementia training Epilepsy training Enteral peg feeding Protection of Vulnerable Adults The Support Team Manager spoken to also spoke of STMs doing a certificate in team leading. The staffing structure for providing formal supervision is as follows: the registered manager supervises the support team managers who in turn support the direct care staff. The manager on duty spoke of aiming for formal supervisions every month, however staff spoken with spoke of formal supervision taking place very infrequently, although they stressed that this was often dependent upon the respective manager. They were also at pains to point out that access to informal supervision was good. The manager spoken with spoke of not having received any formal training in preparing them for this role. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 17 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): 39 and 42. The home needs to ensure that evidence is available that indicates that a process in place for reviewing and keeping under review the quality of the home’s service provision. The home’s record of safe working practices was seen to be in order. EVIDENCE: The manager presented a file of questionnaires that had been used to seek a baseline view of service users using the home’s respite care service. However, no further evidence was presented that indicated that the home has in place a process for reviewing and keeping under review the quality of its service provision. The following safety certificates were sampled in respect of safe working practices at the home: • • Lifting equipment inspection report Boiler inspection report DS0000034854.V255569.R01.S.doc Version 5.0 Page 18 Bridgemarsh • • • • • • Gas safety certificate Electrical installation certificate Portable appliance test reports Record of fire drills Record of fire warning system tests Record of emergency lighting tests. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 19 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 2 x x x x Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 2 2 x x 2 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 2 3 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bridgemarsh Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x 1 x x 3 x DS0000034854.V255569.R01.S.doc Version 5.0 Page 20 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 YA1 Regulation 6 Requirement The registered 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 registered person must ensure that risk assessments are carried out in respect of all service users, based upon their assessed needs. The registered person must ensure that the home’s Complaints Procedure complies with regulatory requirements. The registered person must ensure that service users are protected from the risk of being harmed or abused (this relates specifically to the need for all staff to be trained in recognising and responding to allegations of abuse) The registered person must ensure that the home is kept clean and reasonably decorated (this relates specifically to a number of rooms where the floor coverings were noted to be badly stained) DS0000034854.V255569.R01.S.doc Timescale for action 31/12/05 2 YA9 13(c) 31/12/05 3 YA22 22 31/12/05 4 YA23 13 (6) 31/01/06 5 YA26 23 (d) 31/12/05 Bridgemarsh Version 5.0 Page 21 6 YA27 23 (2a) 7 YA34 19 Schedule 2. 8 YA36 18 (2) 9 YA39 24 The registered person must ensure that the premises are fit to meet the needs of service users. The previous timescale of the end of August 2005 was not meet. The registered person must ensure that documents regarding staff recruitment are maintained as per Schedule 2 of the Care Homes Regulations. The previous timescale of the end of August 2005 was not meet. The registered person must ensure that all persons working at the home are appropriately supervised. 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. 30/11/05 31/12/05 31/12/05 31/12/05 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 YA 30 Good Practice Recommendations It is strongly recommended that sluice rooms are not used as storage facilities, as those seen on the day of the inspection were felt to constitute a potential risk to staff health and safety. Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Bridgemarsh DS0000034854.V255569.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!