Inspection on 16/07/07 for Bridgewater Park Care Home

This inspection was carried out on 16th July 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Bridgewater Park Care Home 09/08/06

Bridgewater Park Care Home 12/01/06

Bridgewater Park Care Home 02/06/05

Bridgewater Park Care Home 10/11/04

Bridgewater Park Care Home 12/05/04

Bridgewater Park Care Home 12/02/04

Bridgewater Park Care Home 08/12/03

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Bridgewater Park Care Home Bridgewater Road Scunthorpe North Lincolnshire DN17 1SN Lead Inspector Stephen Robertshaw Key Unannounced Inspection 16th July 2007 09:30 X10015.doc Version 1.40 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 Bridgewater Park Care Home DS0000002775.V346326.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 Older People. 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. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridgewater Park Care Home Address Bridgewater Road Scunthorpe North Lincolnshire DN17 1SN 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) 01724 847323 01724 847309 bridgewaterpark@meridiancare.co.uk Meridian Care Limited Ms Julie Ann Moult Care Home 53 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (22), Old age, not falling within any other of places category (30), Physical disability (20), Physical disability over 65 years of age (20) Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The two places registered for DE are age limited to those over 55 years 9th August 2006 Date of last inspection Brief Description of the Service: Bridgewater Park is a 53-bedded purpose built care home. The home is situated on a residential development on the edge of Scunthorpe. The home is close to major transport links. The home provides for a variety of needs including nursing care and care for those with a cognitive impairment. The service users accommodation is all on the ground floor and is separated into two units one of which deals particularly for those with cognitive impairment. The rooms are all single occupancy and all but one have en-suite toilet facilities. The home provides a variety of communal space including a smoking room and sensory room. The home provides a variety of bathing /shower facilities to meet service users needs. The gardens are pleasant, accessible to all service users and secure. The current fees for services provided through the home are between £327.20 and £386.20 per week. Some additional fees are incurred when service users are funded through the health authority. Copies of previous inspection reports are made available to service users and visitors to the home in the main entrance. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the service took place on 16th July 2007. The visit was unannounced and the inspector was in the home for approximately six hours. The information included in this report has been gathered over a period of time since the last inspection. This includes an Annual Quality Assurance Assessment (AQAA) that had been completed by the management of the home and was returned to the Commission before the site visit took place. No surveys were sent out to service users, family or professionals due to the lack of time available between the site visit and the receipt of the AQAA. The inspector spoke with three of the service users social workers to gain their views of the services provided by through the home. On the day of the site visit the inspector also read through documentation maintained in the home and spoke with eight service users, seven visitors to the home (families and friends), four professional visitors to the home, interviewed six members of the care staff and the manager of the home. What the service does well: What has improved since the last inspection? Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 6 The records of when service users receive medical treatments has improved this means that the staff can clearly identify if any additional support is needed to support the service users. Service users care plans are checked by the home on a regular basis to make sure that they are doing the right things for the service users. Doors are no longer kept open with wedges and most have automatic closure fittings on them. This means that service users would be protected in the event of a fire at the home. The care and nursing staff receive the right training when they start to work at the home to make sure that they have the knowledge and skills to care for the service users. 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. The summary of this inspection report can be made available in other formats on request. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that prospective service users are provided with an opportunity to visit the home to make sure that it will be suitable to meet their needs. EVIDENCE: The home had an updated statement of purpose in position and the service user guide was in the process of being updated. The statement of purpose gives details of who is responsible for the service and identifies the responsibility of the manager and the aims and objectives of the service. The statement also includes the numbers of staff available and the qualifications that the staff hold. Fees for care services are also identified. Service users and visitors spoken to by the inspector stated that they had access to this document. Individual copies of the service user guides are available in all of the individual bedrooms. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 9 The manager of the home maintains a central file for all of the service users terms and conditions of their residency with the home. Where appropriate these are also supported with contracts from the correct funding authorities. The inspector case tracked four of the service users living at the home. They had all received an assessment of their needs before they had been admitted to the home to make sure that they could be met there. The assessments were a combination of the home’s pre-admission assessment and assessments completed by the appropriate funding authorities. There was evidence that when service users original needs had changed a new assessment of their needs was completed and their new needs were identified. This included how their care would be funded at the home. The training plan for the home, direct observations completed by the inspector and discussions with service users, visitors and care staff supported the evidence that the home can clearly meet the needs of the service users. A service users told the inspector, “the nurses and that (care staff) look after you well here”; another service user commented, “it’s nice and quiet here…no-one to bother you.” These comments were supported through a discussion with a professional visitor to the home who stated, “I visit many homes and this is one of the best. The staff always have the right information ready for you and the residents are well looked after”. The service users or their representatives are provided with an opportunity to visit the home before they make a decision to move there on a more permanent basis. There was evidence recorded in individual service users’ care files that identified when they visited the home. A visitor stated to the inspector ‘we looked around several different homes before we decided to come here’ and a service users said ‘I had been here before to see someone and I liked it here’. The home does not provide intermediate care to service users. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users’ healthcare needs are generally met through the services provided at the home, however, there are some areas that continue to need improvement. EVIDENCE: The inspector case tracked four service users that were living at the home. All of their individual care files included plans of the care that they receive through the home. The care plans had been reviewed on a regular basis to make sure that they were still relevant to the needs of the service users. There was evidence that where appropriate new care plans had been introduced to meet the changing needs of service users and others that were no longer appropriate had been removed. However one of the service users care plans showed that when care plans were completed a line was drawn through them and a new document did not replace them. This could cause some confusion as Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 11 the carers may then miss different elements recorded on the care plan. It would be more appropriate for these documents to be updated and be replaced with new documentation. The care plans included all of the health and personal care needs that were identified in their assessment of needs. The only problem identified was that there was no consistency in the recording of the service users weights at the home. It is important to weigh the service users on a regular basis as this can help to identify any changes in their healthcare needs. The service users care records showed that they have contact with appropriate healthcare professionals to help the home to support their healthcare needs. This included contact with GP’s, chiropodists, dentists, opticians and community nurses. A Community nurse stated to the inspector that they ‘visit the home on a regular basis and always see the residents in private’ they also went on to say that id the service users needed help to attend the appointment then the ‘care staff would support them’. Service users also supported this evidence to the inspector; one said ‘I always see the nurse or doctor by myself in private’. The medication procedures in the home were very good. This was an improvement from previous inspections. The medicine cabinets were never left unattended or unlocked in the communal areas of the home. The staff that administer medication to the service users are either qualified nurses or they had received appropriate accredited medication training. At the time of the inspection many of the care staff and nurses were in the process of updating their medication accreditation courses through a local college. The home has two medication rooms, one in either side of the home. Both of these rooms were well organised and were clean and tidy. The inspector observed staff administering medication to service users and all appropriate legislation and good working practices were followed. The inspector observed the medication records for the four service users that were case tracked and all of their records were up to date and had been accurately recorded. There were no omissions on any of the Medication Administration Record Sheets that were seen by the inspector. The home has a controlled medication cupboard in one of the medication rooms. This had an appropriate double locking system. All of the controlled medication was appropriately stored and recorded. As in line with good working practices the Temazepam in the home was stored as a controlled drug. To continue with good working practices it would be appropriate to also record the Temazepam as a controlled drug to make sure that none of the medication could be ‘misplaced’. The inspector’s observations supported the evidence that the service users privacy, dignity and respect are upheld at all times at the home. One service user said ‘I see who I want to, on my own if I want to’. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 12 The home provides end of life care for many of the service users that are admitted to it. A visiting professional stated to the inspector that the care provided to the service users in these circumstances was ‘very good, and that is why this care is contracted with the home’ they also went on to say that ‘the staff are very good and they know how to look after the service users well’. Service users have a call system available to them in their rooms. One service user said, “The nurses look after you well, I have a buzzer and if I call they come.” Another service user stated that the staff “don’t take much notice of the buzzer.” The inspector’s observations supported that when call bell was used the staff were quick to respond to it. The care staff stated that the only time that there were any minor delays in responding to buzzers was when they were already responding to the needs of other service users. One of the service users’ care files identified that bed rails were used to support their care in the home, however there was no risk assessment to support how this equipment should be used to ensure their safe use and the safety of the service user. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users are encouraged to maintain the interests that they had before they were admitted to the home, however the activities provided through the home are not varied or stimulating. EVIDENCE: The service users’ care files identify any involvement that they have in activities provided in the home and in the community. There assessment of need also include any interests that they had before they had been admitted in to the home. Most of the service users spoken to by the inspector stated that they were happy with the frequency and variety of the activities provided to them at the home. The activities that were included bingo and coffee mornings that service users friends and relations were also invited to. Several of the service users in the home also had dementia related problems. There was no evidence to support they specialist activities to stimulate these service users were Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 14 available. The manager of the home stated that both sections of the home have a member of staff that is responsible for developing appropriate activities for the service users. She went on the say that it was recognised that this was a difficult are to recruit to. A visitor to the home stated that the care provided was ‘very good’ but added ‘it would be better if their were more things for the residents to do’. The care staff record the daily activities that the service users are involved in and this also includes the interactions between the staff and individual service users. These records were written in a very clinical manner and did not include any of the social aspects of the interactions with the service users such as were they happy with the things that they were doing, were they overall happy or upset. It would benefit the service to develop these records further. This would help to identify any patterns of behaviour for individual service users and enable the care staff to intervene before problems arose or became more serious. Visitors to the home and service users confirmed to the inspector that they can visit at any reasonable time. During the course of the site visit there were many visitors to the home and the inspector spoke with eight family and friends that were visiting. One visitor stated ‘the home is always very welcoming and there are always staff that you can talk to’. Service users are provided with personal autonomy and choice throughout their daily lives at the home. This included the times that the got up in a morning and the time that they retired to bed. The inspector also observed that service users could also choose where they wanted to eat their meals. All of the service users care files seen by the inspector included an assessment of their nutritional needs. The kitchen staff were aware of all of the dietary needs of the current service users. The service users were generally very positive in relation to the meals that they receive at the home. A cooked breakfast is available in the home every day of the week. There are two dining rooms in the home and both of these are in conservatory areas. Both of these areas were exceptionally and uncomfortably hot on the day of the site visit. The residents in the residential/nursing unit at the home have to have two sittings as the dining room is not big enough to accommodate all of the service users in this area. One service user stated ‘the meals are fine, sometimes you have three choices of what to eat’. However one service user said to the inspector ‘I sit on my own for all my meals, I would rather sit with someone else, someone to talk to’. The inspector mentioned this to the care staff who assured the inspector that all of the service users were able to sit with others at meal times and did not have to sit alone. The inspector observed the service user in question sitting with other service users for their dinner. The inspector also looked around the homes kitchen. The area was clean and tidy and there were good stores of food in the home. However the records for Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 15 the temperatures of the fridges and freezers and the hot food temperatures were not maintained on a regular basis. This must be improved to support the health and safety of the service users and the staff at the home. The home has a hairdressing room and a local hairdresser visits the home on a weekly basis to cut service users hair. The hairdresser pays rent to the home for using the services provided there. The inspector observed several service users having their hair cut. This was carried out in a very relaxed and calm atmosphere. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the service users are supported with a robust complaints procedure and are protected from possible abuse at the home. EVIDENCE: The home has a robust complaints policy and procedure. The inspector observed the complaints records in the home. All of the concerns registered had been recorded and had been responded to in an appropriate manner. The complaints procedure was available in the communal areas of the home and service users and visitors were aware of how to make a complaint in relation to the service if they had one. One visitor said’ I have never had to make a complaint but if I did I know that it would be dealt with properly’ and a service user said ‘If I had a complaint I would talk to the nurse. Since the last inspection the Commission did not directly receive any complaints in relation to the services provide through Bridgewater Park. Where appropriate, service users’ care files showed that they are supported to vote at local and national elections, and also identified if anyone else was responsible for their financial transactions. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 17 The staff are provided with Safeguarding Adults training. The staff spoken to were all aware of safeguarding adults policies and procedures and were clear of how to report any suspicions or allegations of abuse. The staff employment records showed that the staff receive the appropriate safety checks before they are employed to work with the service users. Since the last inspection there had been no cases reported to the local safeguarding adults team. The home’s policies and procedures in relation to the protection of vulnerable adults gives out the wrong information. It states that any allegations or suspicions of abuse should be reported to a senior manager with the company who will then instigate an investigation. Any allegations or suspicions must be reported to the local safe guarding adults team and they will determine if an investigation needs to be carried out and who will be involved in the investigation. This brochure should not be distributed until it has been appropriately updated. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the environment provided for the service users in generally good, however the temperature of the home was very hot and at times was uncomfortable for the service users. EVIDENCE: The inspector made a tour of the premises. The home was very well furnished and decorated in a manner that supported a homely environment. The day of the site visit was very hot outside and this was reflected in the temperature inside the home. Both of the dining areas are in conservatories and were exceptionally warm and uncomfortable. The temperatures in the homes corridors were recorded on the home’s thermometers between 23° and 26°C. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 19 One service user said to the inspector ‘I wish that there was a window that I could open to keep cool’. The care staff agreed that the dining rooms were very warm and suggested that if it was too hot for the service users to eat in there then they could eat in their bedrooms. The shower, toilets and bathrooms in the home were clean and free of any offensive smells. However there were potential infection control problems in one of the shower rooms as there were five used blocks of soap and linen towels left openly in this area. Staff training records showed that they receive infection control training and interviews with them supported the evidence that they are aware of how to support the service’s policies and procedures to maintain infection control in the home. A visitor to the home stated to the inspector ‘It’s surprising with all the problems that the residents have that the home always smells fresh. The home employs a team of domestic staff that maintain the environmental standards in the home. Four service users invited the inspector to look at their rooms. These had all been decorated and furnished in respect of their personal tastes and preferences. One service user commented ‘my room is always kept clean and tidy’. The appropriate maintenance checks are carried out on all of the equipment used in the home and the records to support this were up to date and were accurately recorded. The laundry in the home was well organised and the washing machines had automatic feeds on them to minimise the staffs contact with caustic substances. The washing machines were of an industrial quality and were programmable to disinfection and sluicing standards. The home also has a separate sluice room. This room is usually locked due to the hot water temperatures in it and the soiled materials. However it was left unlocked on the day of the site visit any anyone including service users with dementia related needs could have accessed it. As referred to earlier in this report the kitchen staff must keep better records of the fridge, freezer and prepared food temperatures to ensure the health and safety of the service users. The manager accepted that this has been an ongoing problem in the home and says it is a responsibility of the kitchen staff to complete. The manager of the home also has a responsibility to make sure that these safety checks are completed on a regular basis. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the staff receive the right training to make sure that they can safely look after the service users in their care. EVIDENCE: The inspector spoke with several visitors to the home, both professional and family/friends and they were all very complimentary in their comments in relation to the nursing and care staff working in the home. One professional commented ‘the staff and care are much improved.they are very good and the staff are very knowledgeable and supportive’. The staff records indicate that there are always appropriate staff on duty at the home except in very exceptional circumstances. A service user stated ‘there is always someone to see to you’. The inspector’s observations also demonstrated that the staff were in appropriate numbers to care for the needs of the service users. The staff training records and the manager’s records showed that 61 of the care staff have so far achieved National Vocational Qualification (NVQ) at level 2 in care. This is over the required minimum of 50 . The care staff and Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 21 management that were spoken to by the inspector were very positive towards NVQ training. No care staff employed in the home were under twenty-one years. The home also employs domestic care staff and kitchen staff. The records also demonstrated that these were employed in appropriate numbers to maintain the environment of the home and the standard of the meals provided. The recruitment procedures in the home support equal opportunities. The staff personnel file showed that they had received the right safety checks before they had been employed to work with the service users at the home. The staff induction and foundation training is in line with the national requirements. The manager of the home stated to the inspector that she keeps a record of the training that staff are involved in and this identifies when any of their training needs to be refreshed or updated. All of the staff working in the home wear uniforms to identify their positions in the home. Several staff reported to the inspector that they are responsible for paying for their own uniforms. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the management of the home supports the care provided to the service users and understands their individual needs. EVIDENCE: The manager of the home is a qualified first level nurse and has also completed qualifications in teaching and management. She has been in a management position in a care home since 1990. The manager has overall responsibility for the home and her hours are all expected to be managerial. The manager stated to the inspector that when a member of the nursing staff is not available she will take on this role to cover any shortfall in the staff rota. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 23 The manager also undertakes regular training to maintain her nursing registration. Service users, visitors to the home and care staff supported that the management approach to the home is open and inclusive. A visitor said ‘the manager is always available if you want to speak to her and she listens to what you have to say. The home has an effective quality assurance and monitoring system. Surveys are sent out to service users and their families to comment on the services being provided through the home. The returned questionnaires are evaluated and an action plan is created from them. These results are then made public. However surveys did not appear to be sent to outside professionals that are involved in the care of the service users. This is an important element in the quality assurance system to identify how other professionals judge the standards of the services that the home provides and to identify if they could recommend any changes that may improve the services being offered to the service users. The appropriate insurance was in position for the business. The inspector sampled three of the service users pocket money accounts and the home service users fund and found all, of these records to be up to date and they had been accurately recorded. Service users care files identified if anyone else was responsible for their personal finances or if they looked after their own monies. Staff supervision records were confusing to the inspector. Staff that provide supervision complete a grid to show in which month supervision has been completed. In most cases seen by the inspector there were more ticks on the grid than there were records for formal supervision. The supervision records indicated that the staff are not receiving the recommended minimum of six formal supervision periods per year. Staff interviewed buy the inspector also indicated that they are not receiving the recommended minimum for formal supervision but added that they can access informal supervision at any time that they need it. The manager of the home ensures that as far as is reasonably practicable the health, safety and welfare of the service users and the staff working in the home. The only concern in this area was in relation to the lack of records maintained by the kitchen staff. Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 X 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation 13.4 (2) 13.7 13.8 Requirement Timescale for action 30/07/07 2. OP8 3. OP12 4. OP15 OP25 The registered person must make sure that when bedrails are used with service users a risk assessment supports the use of them to show that they are safe for the service users. 15(1)13(1 The registered person must 30/08/07 )(b) ensure that specific instructions as to measuring of weight, pressure relief and dressing changes are recorded consistently in care plan documentation and that these instructions are followed by care staff (previous requirement for 01/10/06 was not met). 16(20(m)( The registered person must 30/08/07 n) ensure that service users are consulted about their social interests and develop a programme of activities that meets their needs and wishes (previous requirement of 01/10/06 was not met). 23(2)(p) The registered person must 30/08/07 ensure that the dining rooms can be maintained at comfortable temperature for the service users (requirement of DS0000002775.V346326.R01.S.doc Version 5.2 Bridgewater Park Care Home Page 26 5. OP15 16.2 (g,j) 6. OP18 13.6 7. OP26 16.2 (j) 8. OP36 18.2 09/08/06 was not met) This must also include the corridors and personal rooms in the home. The registered person must make sure that appropriate records are maintained in the homes kitchen to uphold the health safety and personal welfare of the service users. The registered person must make sure that appropriate information is included in the services Protection of Vulnerable adults leaflet to avoid any confusion in relation to where allegations must be reported to. The registered person must ensure that no blocks of soap or linen towels are left in communal toilets and bathrooms to protect the service users from cross infection and uphold infection control policies and procedures. The sluice room in the home must also remained locked when it is not in use. The registered person must make sure that the care staff and nurses receive at least the recommended minimum requirement of six formal supervision periods per year (pro-rata) to identify that they have the right knowledge and skills to support the service users in the home and to identify any of the staffs training and development needs. 30/07/07 01/08/07 20/07/07 30/12/07 Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations The registered person should make sure that when service users care needs change a new care plan is produced to show how they need to be supported and old care plans are not just simply crossed out. The registered person should make sure that the daily recordings of interactions with service users are not just clinical but include personal interactions and moods of service users. This will help to identify any patterns of behaviour for individual service users. The registered person should make sure that when service users activate their buzzers they are responded to in a reasonable time and service users are made aware if there are any delays. The registered person should consider recording the Temazepam in the home in line with the controlled drugs policy and procedure to monitor how much of the medication should be in position. The registered person should ensure that contact numbers for the Local Authorities and the Commission are included in the company’s information booklet regarding abuse. The homes quality assurance and monitoring system should be developed further to include the view of other professionals. This will provide a more effective system for identifying any improvements that are required for the service. 2. OP7 3. OP8 4. OP13 5. 6. OP18 OP33 Bridgewater Park Care Home DS0000002775.V346326.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Bridgewater Park Care Home DS0000002775.V346326.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. 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!