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Inspection on 02/06/05 for Bridgewater Park Care Home

Also see our care home review for Bridgewater Park Care Home for more information

This inspection was carried out on 2nd June 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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was clean and tidy and well decorated. There was lots of space and different places to sit. The chairs in the lounges were very comfortable and different types of chairs were available to meet peoples needs. The home was being redecorated and improved throughout at the time of the inspection. The home was organised into two parts to help keep people safe and there were safe garden areas for people to use. The home had different types of baths and showers and equipment to help people to move around the home. The people who lived in the home all said that they enjoyed the meals and that there was always a choice for every meal. Staff were very good at assisting people who needed help when eating and spent time helping one person at once. Training for the staff was given on a regular basis and care staff had had a wide variety of training to help them do their job safely. The people who lived in the home said that the staff were good and were kind and polite to them

What has improved since the last inspection?

The care plans in the area of the home that cared for people with memory loss were very good and had been kept up to date. This meant that the staff had all the information they needed to provide care. They had also improved the records of when a doctor or nurse had visited. The activities for the people with memory loss had improved and one member of staff arranged the activities in the home. Staff numbers had improved as the staff sickness had gone down. The hot water in the home was now at a safe temperature.

What the care home could do better:

The home provides information about the home but must add other things to make sure that the people who want to live in the home have all the information they need. The care plans written by the nurses must cover all the needs of the people living in the home. All the people living in the home must agree to their plans of care. The temperature of the places where medication was kept must be checked to make sure that the medication will not be damaged. The staff must always record when they have given people their medication. The kitchen must be kept clean and records must be kept to show that the cleaning was done. Records must be kept to show that the food was stored and cooked safely. Checks must always be done to make sure that staff are safe to work in the home before they start. Records of the training given when staff start work at the home must be kept.Nurse training must be given to help them write better care plans, to keep medication safe, to write better records and to update them on care of wounds. The manager must make sure that there is enough staff working in the home to meet the needs of the people living there

CARE HOMES FOR OLDER PEOPLE Bridgewater Park Bridgewater Road Scunthorpe North Lincs DN17 1SN Lead Inspector Kate Emmerson Unannounced 2 June 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 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. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bridgewater Park Address Bridgewater Road, Scunthorpe, North Lincs. 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) 01724 847323 Meridian Care Ltd Mrs Julie Ann Marshall Care Home 53 Category(ies) of DE(E) (22), OP (30), PD (20), PD(E) (20), TI (5) registration, with number of places v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 November 2004 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 ensuite toilet facilities.The home provides a variety of communal space including a smoking room and snoozealam.The gardens are pleasant, accessible to all service users and secure. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two days in June 2005. To find out how the home was run and if the people who lived there were pleased with the care they got the inspector spoke to the manager and 5 of the staff working in the home at the time of the inspection. The inspector also spoke to 8 people who lived in the home and 2 visitors. Some of the records kept in the home were checked. This was to see how the people who lived in the home were being cared for, that staff were safe to work in the home and that they had been trained to their job safely and to make sure that the home and the things used in it were safe and were checked regularly. The home was checked to see if it was kept clean and tidy. What the service does well: The home was clean and tidy and well decorated. There was lots of space and different places to sit. The chairs in the lounges were very comfortable and different types of chairs were available to meet peoples needs. The home was being redecorated and improved throughout at the time of the inspection. The home was organised into two parts to help keep people safe and there were safe garden areas for people to use. The home had different types of baths and showers and equipment to help people to move around the home. The people who lived in the home all said that they enjoyed the meals and that there was always a choice for every meal. Staff were very good at assisting people who needed help when eating and spent time helping one person at once. Training for the staff was given on a regular basis and care staff had had a wide variety of training to help them do their job safely. The people who lived in the home said that the staff were good and were kind and polite to them v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The home provides information about the home but must add other things to make sure that the people who want to live in the home have all the information they need. The care plans written by the nurses must cover all the needs of the people living in the home. All the people living in the home must agree to their plans of care. The temperature of the places where medication was kept must be checked to make sure that the medication will not be damaged. The staff must always record when they have given people their medication. The kitchen must be kept clean and records must be kept to show that the cleaning was done. Records must be kept to show that the food was stored and cooked safely. Checks must always be done to make sure that staff are safe to work in the home before they start. Records of the training given when staff start work at the home must be kept. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 7 Nurse training must be given to help them write better care plans, to keep medication safe, to write better records and to update them on care of wounds. The manager must make sure that there is enough staff working in the home to meet the needs of the people living there 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. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The home provided information to service users to assist them to make an informed choice about where to live. Whilst the documents provided were generally informative, they need further development to meet the Standards and Regulations EVIDENCE: The home has worked through various drafts of the documents required by regulation over previous years. Draft copies of both the Statement of Purpose and Service users guide was provided to the inspector. Examination of these documents showed that the statement of Purpose did not include all the information required by the regulations. For example the document must include the arrangements for consultation with service users, details of fire precautions fire precautions and associated procedures, arrangements for review of care plans and arrangements for respecting privacy and dignity. The service users guide did not include all the information required to meet the standards such as relevant qualifications and experience of the registered provider or a copy of the most recent inspection report. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 ,8 and 9 The health, personal and social care needs of the service users in the EMI unit were being met and detailed care plans were in place. Service users on the nursing unit were at risk of basic care needs and health care needs not being met due to inconsistent care planning and care practises. Inconsistent practise and inaccurate record keeping could put service users at risk of not receiving the correct medication at the correct time. The lack of monitoring of temperatures of the drug fridge and storage areas could lead to incorrect storage reducing the medications effectiveness. EVIDENCE: v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 11 A random selection of 8 care plans was examined. Each service user had an individual plan of care. The format was well developed with basic individual risk assessments in place. An improved and more detailed format for risk assessments had been developed and was in place in some of the care plans. This must applied through the home, as some of risk assessments and action plans to minimise risk were poo, particularly on the nursing unit. The care plans in the EMI unit had been well maintained and were detailed and up to date. The recording of health professional’s visits and outcomes had improved and were now more detailed. The care plans completed by the nurses were inconsistent in quality and content and did not reflect all the service users needs. In 4 care plans risk assessments indicated that the service users were at risk of pressure sore development but care plans had not always been completed. Staff were able to confidently describe the care required to prevent pressure sores and described the procedures in the nursing unit however practises were ad hoc with care provide at any time between 2 – 4 hourly. The staff were not completing turn monitoring charts on a consistent basis and therefore it could not always be assessed if adequate care had been provided. Plans for wound care and records of wound care provided were inconsistently maintained and did not reflect the service users needs. The care plan had not been updated to reflect the needs of a service user who had sustained a fracture and had a plaster of Paris pot applied. It was observed that the basic care on the nursing unit was not adequate with regard to nail care and ensuring service users were dressed appropriately. Service users were put at risk form being left sat in wheel chairs without brakes applied. Monthly evaluations of the care plans had been completed but the evaluations on the nursing unit were inconsistent in quality of information recorded and they did not cross-reference to recent events such as falls or monitoring charts. As the evaluations were not effective, not all the care plans had been adequately updated to reflect changing needs. There was some evidence that the service user or their representative had been consulted on and agreed the care plan, this needs to be applied more consistently. The inspector observed a medication round, examined medication records and spoke to staff and service users regarding practises in the home in relation to medication. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 12 The service users all stated that they received their medication at an appropriate time and were offered pain relief when required. They stated that the home always had stocks of their medication. There were errors noted in 6 service users medication administration records across the home. Errors included: not signing where medication had been given or signing when it hadn’t been given, medication prescribed on an as required basis for a skin condition on an as required basis had been given every day although records did not support the service user having had any problems, a monitored dosage system contained one and a half tablets but only the whole tablet had been given on one day and the half remained in the packet and medication had been given from the morning system but signed as the evening medication, The temperature of the storage facilities and drug fridge had not been recorded since December 2004. This could affect the viability of the medication. There was a formal system to identify service users on the nursing unit but not on the EMI unit. On the EMI unit there was one medication on the that was out of date and another that belonged to a service user who was no longer at the home. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals were of good quality with choices appropriate to service users needs. The dining rooms were very pleasant and offered appropriate seating. Although staff offered appropriate support to those unable to feed themselves, staffing was inadequate over the lunch time period leading to unacceptable task orientated care between sittings EVIDENCE: v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 14 The dining rooms in the home had been decorated providing very comfortable and pleasant areas. Seating was appropriate to service users. Despite the fact that staff were extremely busy over this period the staff were seen to offer individual assistance with meals discreetly and sensitively. Service users described the food as – ‘very good’,’ excellent’, and ‘good choices’. The meal observed was well presented with good portion sizes. There were 2 choices of main meal offered at lunch time with a choice of vegetables.. At the last inspection there were issues relating to the procedures at lunchtime, which was served over 2 sittings. While this is not an issue in its self the process of the service users being taken to/from the dinning room created unacceptable task orientated care. Those service users who had been to the first sitting were taken back to the lounge, but those who required assistance with transfers had to wait for the second sitting to be seated/served before they were then assisted into comfortable chairs in process known by staff and service users as ‘chairing up’. This involved 2 staff going around the lounge area assisting everyone back into their chairs. It is identified in standard 27 that some of these issues were attributable to the low staffing levels. The registered person must ensure that service users are provided with assistance in a timely manner and that there are sufficient numbers of staff on duty to meet service users needs. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a robust complaints procedure, which is made available to the service users. The home must address the requirements raised in standard 7 – 11 and 27 – 30 to ensure that all the issues raised in previous complaints are fully addressed EVIDENCE: The home had an in-depth policy and procedure for dealing with complaints. The procedure was displayed throughout the home and on the back of bedroom doors. The service users said that they did not know about the complaints procedure but would approach their personal carer or a nurse. Recent complaints recorded in the home and received by the commission were about basic care issues. The evidence from the inspection would indicate that the manager had been proactive in addressing these problems through monitoring systems and staff training, although staffing levels remained an issue. The Commission had received 3 complaints regarding the lack of provision of hot water in the EMI unit and on the nursing unit - poor care practises, low staffing levels and inappropriate medication administration. The complaints were upheld v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 25, 26 The home provided accessible, safe and comfortable communal facilities. The garden areas are accessible and secure. The areas accessed by the service users were clean and tidy and well maintained. The company were investing in an extensive refurbishment programme to improve the environment for the service users. The kitchen was very dirty and records relating to the safe storage and preparation of food had not been maintained this could expose service users to unacceptable risks to their health and wellbeing EVIDENCE: v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 17 The home provides purpose built ground floor accommodation with access to secure garden areas. All bedrooms except one have ensuite facilities and toilets are situated close to communal areas. The home provides a wide variety of bathing and/or showering facilities with high quality fittings to meet service users needs, including a walk in bath and a level floor shower. At previous inspections it had been recommended that the registered person should consider the provision of communication aids and signs for those with sensory impairment and dementia, there was no evidence that this had been completed. The registered person should demonstrate that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. The home was undergoing an extensive programme of refurbishment and redecoration. The communal areas had been completed and some new flooring had been provided near the nurse’s stations and in dining rooms. The manager must monitor this flooring to ensure that it does not become slippery under foot when wet. The home was generally clean and tidy. Sluicing facilities were provided separate to service users facilities. An immediate requirement served at the previous inspection regarding hot water temperatures had been met. The HACCP and cleaning records in the kitchen were still not consistently maintained and this must be addressed. Some of the kitchen wall tiles were missing and needed replacing. The kitchen was very dirty, the floors under shelving, Bain-Marie, cooker, fryer, walls, shelving and grill pan all required cleaning. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Staffing levels on the EMI unit had been maintained and staff had received a variety of training to assist them in their role. This was reflected in the improved basic care and care planning in this unit. Staffing levels on the Nursing unit had not been maintained to the minimum guidelines and although care staff had received a variety of training there was little evidence that the nursing staff attended training specific to their role. This was reflected in the care provision and of care planning as seen in earlier standards. The recruitment practises did not afford adequate protection for the service users. To ensure safe practise and protection of service users all staff must have a new CRB check before employment. Although there was a process for inducting staff in their role, record keeping in this area was poor EVIDENCE: The service users stated that the staff were good and assisted them when they needed help. Whilst the staffing levels in the EMI unit had improved and been maintained consistently the levels on the nursing unit had not been maintained at adequate levels. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 19 Discussions with service users, staff and visitors indicated that whilst the staffing was more consistent due to a reduction in sickness levels amongst the staff group, weekends remained a problem on the unit. The staffing levels for the 20 nursing service users and 11 residential on this unit as a minimum must be maintained as 1 nurse plus 6 carers morning shift and 1 nurse and 5 carers afternoon/evening shift. In the week prior to the inspection the home had not achieved these figures on any shift. This is not acceptable and affects care delivery as seen in standards 7 – 11 and 12 – 15. The manager had accepted CRB checks from previous employers in 3 of 4 cases examined and 1 staff member had had no CRB check completed prior to employment. The manager was advised that CRB checks are not portable due to POVA checks being required in every case before employment and these can only be completed with a new CRB. The home had an in-depth induction workbook for staff and in 3 of the 4 cases above records were held but only the first week had been completed in each case even though at least 2 of these staff had commenced employment in April 2005. Care staff described the wide variety of training available to them and records showed that mandatory and service user specific training was provided. One member of staff had completed the training for trainers course in moving and handling. Staff stated that they had received moving and handling training that included practical tuition in the use of equipment and improved techniques were observed during the inspection. Whilst it was noted that the care staff had attended a variety of training only one nurse, the deputy manager, had attended a wide variety of further training appropriate to her role. Another nurse as requirement arising from a complaint was in the process of completing an infection control course and had completed pressure area care, basic food hygiene, appointed persons first aid and protection of vulnerable adults. Another nurse had completed wound care in 2003 and pressure area care training in 2004. The manager stated that training was available for all the trained staff but there was a lack of motivation. Considering the deficiencies in this unit, training for the nurses is a priority in areas such as safe handling of medication, care planning, record keeping, wound care and pressure area care. (See standards 7 – 11) v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 The manager took positive actions to ensure the health and safety of the service users and staff and had been proactive in meeting previous requirements. Service users were at unacceptable risk of falls as staff failed to apply brakes to wheelchairs EVIDENCE: v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 21 Some of the records as listed in schedules 3 and 4 of the Care Home Regulations were well maintained although the deficiencies in the statement of purpose, service users guide, staff recruitment records and care plans. Evidence from policies and procedures, records, and staff discussions showed that the manager did take positive actions in ensuring the health and safety of staff and service users. Staff stated that there was sufficient moving and handling equipment provided in each area including individual slide sheets for service users. One staff member had completed training for trainers in moving and handling. Moving and handling training had been provided to staff since the last inspection and improved moving and handling techniques were observed during the inspection. The manager had addressed health and safety requirements form the previous inspection. The inspector was concerned at the number of times the staff failed to apply brakes to wheelchairs when service users were left sitting in them. The service users were being put at unacceptable risk of falls. Accidents were appropriately recorded. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 2 x x 3 2 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x 2 x x x 2 v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 23 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 OP1 Regulation 5 Requirement The registered person must include the most recent inspection report in the service users guide.(Previous timescales by with immediate effect not met). The registered person must include in the Statement of Purpose the arrangements for consultation with service users, fire precautions and associated procedures, arrangements for review of care plans and arrangements for respecting privacy and dignity. The registered person must include in the service users guide relevant qualifications and experience of the registered provider. The registered person must ensure that care plans on the nursing unit reflect the care required by service users. (Previous timescales by 31 July 2004 and 1 February 2005 not met) The registered person must ensure that the service user or their representative have been consulted on and agreed their v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Timescale for action 2 June 2005 2. OP1 4 1 August 2005 3. OP1 5 1 August 2005 4. OP7 15 31 August 2005 5. OP7 15 31 August 2005 Version 1.40 Page 24 6. OP7 15 7. OP8 15 8. OP9 13(2) 9. OP9 13(2) 10. OP15 18(1)(a) 11. OP27 18(1)(a) 12. OP26 16(2)(j) care plan. (Previous timescales by 31 July 2004 and 1 February 2005 not met) The registered person must ensure that care plans on the nursing unit are regularly and effectively reviewed and records are maintained to evidence this. (Previous timescale - with immediate effect - not met). The registered person must ensure that care plans on the nursing unit are regularly and effectively reviewed and records are maintained to evidence this. (Previous timescale - with immediate effect - not met). The registered person must ensure that accurate records of drug administration are maintained. The registered person must ensure that medication is stored at correct temperatures and that there are adequate systems for disposal of medictaion when out of date or on the death of a serivce user. The registered person must ensure that service users are provided with assistance in a timely manner. Staffing at meal times must be reviewed to ensure that there are sufficient numbers on duty to meet service users needs.(Previous timescale by 1 January 2005 not met). The registered person must ensure that service users are provided with assistance in a timely manner. Staffing at meal times must be reviewed to ensure that there are sufficient numbers on duty to meet service users needs.(Previous timescale by 1 January 2005 not met). The registered person must ensure that the kitchen and all 2 June 2005 2 June 2005 2 June 2005 2 June 2005 2 June 2005 2 June 2005 31 July 2005 Page 25 v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 13. 14. OP26 OP26 23(2)(b) 13(4) 15. OP27 18(1) 16. OP29 19 17. OP30 19(1) (a) 18. OP30 19(1)(a) 19. OP38 13(4) 20. OP37 17 the equipment in the kitchen is thoroughly cleaned. the cleaning schedule must be maintained. The registered person must ensure that the missing wall tiles in the kitchen are replaced. The registered person must ensure that food is stored and prepared within HACCP guidelines and associated records are maintained.(Previous timescale - with immediate effect - not met).. The registerd person must ensure that minimum staffing levels are maintained on the nursing unit. Staff rotas must be provided to the Commission on a weekly basis until further notice. The registered person must ensure that all staff have a CRB check prior to commencing employment. The registered person must ensure that induction is completed in the specified time of 6 weeks and foundation training within 6 months and that records are adequately maintained to evidence this.(Previous timescale - with immediate effect - not met).. The registered person must ensure nursing staff access refresher training appropriate to their role including care planning, safe handling of medication, record keeping, wound care and pressure area care. The registered person must ensure that service users are not put at risk whilst seated in their wheel chairs through the non application of brakes. The registered person must ensure that all records as listed in Schedules 3 and 4 of the 31 July 2005 2 June 2005 2 June 2005 2 June 2005 2 June 2005 1 September 2005 2 June 2005 2 June 2005 Page 26 v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 regulations are maintained and up to date(Previous timescale with immediate effect - not met).. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP22 OP22 Good Practice Recommendations The registered person should consider the provision of communication aids and signs for those with sensory impairment and dementia The registered person must demonstrate that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3. 4. 5. 6. 7. v229256 j54 bridgewater 2775 v229256 ui 2.6.05.doc Version 1.40 Page 27 Commission for Social Care Inspection Unit 3, Hesslewood country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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