Inspection on 28/11/07 for Bridgewood House

This inspection was carried out on 28th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bridgewood House 19/11/08

Bridgewood House 30/08/07

Bridgewood House 24/01/06

Bridgewood House 19/09/05

Bridgewood House 18/10/04

Bridgewood House 14/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Bridgewood House 165 Barnsley Road Denby Dale Huddersfield West Yorkshire HD8 8PS Lead Inspector Alison McCabe Key Unannounced Inspection 28th November 2007 11:20 Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bridgewood House Address 165 Barnsley Road Denby Dale Huddersfield West Yorkshire HD8 8PS 01484 861103 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) lmacdonald@bridgewoodtrust.co.uk Bridgewood Trust Limited Care Home 23 Category(ies) of Learning disability (23), Physical disability over registration, with number 65 years of age (23) of places Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2007 Brief Description of the Service: Bridgewood House is a care home providing personal care and accommodation for twenty-three people with learning disabilities. It is owned by the Bridgewood Trust, a voluntary organisation providing a range of services in the field of learning disabilities for people in the Kirklees area. The home is situated on the outskirts of Denby Dale, a small community midway between Huddersfield and Wakefield. The home was purpose built for care. It consists of a single level home accommodating nineteen service users and 4 self-contained bungalows built in the grounds. All but two of the rooms in the care home are for single occupancy. There is a good range of communal facilities in the home. The home has large, well maintained gardens. The standard fees charged by the home range from £ 307.56 to £ 899.55 with additional charges made for hairdressing, chiropody, toiletries etc. Bridgewood House provides information about the home to residents in its Statement of Purpose and Service User Guide. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out using information supplied by the acting manager in the form of a self-assessment, and a visit to the home. Surveys were not sent out on this occasion as the home had undergone a key inspection on 30 August 2007 when people living at the home, relatives, health care professionals and staff completed surveys. During the inspection visit, the following records were examined: individuals’ care plans, risk assessments, medication and associated records, daily records, accident and incident reports. Staff training and recruitment records were also seen. The inspector conducted a tour of the premises. As part of the inspection visit, the inspector had discussion with staff working at the home and some of the people living at the home. Feedback from people living at the home was positive. In view of the fact that many of the people living at Bridgewood House are not easily able to verbally express their views of the service, the inspector spent time observing care practice and interactions between staff and people living at the home. Since the last key inspection in August 2007, the pharmacist inspector has conducted an additional inspection visit on 28 September 2007. This was as a result of the poor medication practice that was identified at the key inspection in August 2007. It is positive that the improvements noted at the additional inspection have been maintained. A copy of the pharmacist inspector’s report can be made available on request to members of the public or other enquirers. The inspector would like to thank everyone for their assistance during the inspection process. What the service does well: People’s needs are assessed before they move into Bridgewood House. Good information about how people’s needs should be met and how to minimise risks is available. Good support is given to help people to make choices and decisions. People living at the home lead a reasonably active lifestyle. People are supported to keep in touch with family and friends. People have a healthy and varied diet and enjoy the food. People receive personal support in the way they prefer and require. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 6 Most people’s health care needs are met appropriately. People are protected from harm or abuse and procedures are in place for dealing with complaints appropriately. People know how to make a complaint. People live in a comfortable home with plenty of space. A skilled staff team supports the people living at Bridgewood House. Recruitment practice is generally good, protecting the people living at the home. Satisfactory quality assurance systems are in place. The manager has positive relationships with people living and working at the home. What has improved since the last inspection? 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 Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 8 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 Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed prior to them being admitted to Bridgewood House. EVIDENCE: There was evidence in the records sampled that people’s needs are assessed before they move into the home. Community Care Assessments completed by the care manager were in place in addition to a detailed assessment of needs conducted by the home. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. In general, good information about how people’s needs should be met and how to minimise risks to people is available, and good support is given to help individuals make choices and decisions. EVIDENCE: Two care plans were examined, and both contained some really good information about how each individual’s needs should be met. There was evidence that, wherever possible, individuals are encouraged to participate in the care planning process. An example of this is one individual had asked that he typed up his own care plan for his file. It is good practice that this has been supported. The acting manager reported that the individual had really enjoyed taking part in the process. Further information needs to be added to some areas, for example, how often an individual is supported to have a cigarette, to Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 11 ensure that staff consistently meet individuals’ needs. Regular reviews of the care plans take place and evidence of this is recorded. Staff maintain daily records to evidence that the agreed care has been provided, however the records do not always contain sufficient detail so as to ascertain that an individual’s needs have been met. It is recommended that, if abbreviations are to be used in daily records, a key is available to ensure that all staff are clear about what is being recorded. It was noted that abbreviations are used regularly and when staff were asked to explain what they meant they were not sure of all of them. A member of staff also commented that abbreviations are particularly difficult for people with dyslexia. It was suggested at the last inspection that a record be kept of why individuals have been prescribed medication so that staff can monitor effectiveness. This has not yet been included, and is a recommendation of this report. Risk assessments were examined and were generally found to contain clear information to staff about how to minimise identified risks. Further development of some is required. For example, where it indicates that a fluid balance chart needs to be kept, there needs to be clear information for staff about expected input/output and what action to take if the input/output is not as expected. The Bridgewood Trust is in the process of implementing revised care planning and risk assessment documentation. The area manager is supporting the acting manager with this process and expects that gaps in the current documentation will be identified and addressed when the new paperwork is adopted. Throughout the inspection visit, staff were observed to encourage and support individuals to make choices. This included choices about what to eat, drink, and what to watch on television. A senior member of staff confirmed that individuals had been consulted about the new colour scheme for the building, and that pictures are used to support people to make choices about meals. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home lead a reasonably active lifestyle, are supported to keep in touch with family and friends, have their rights respected and have a healthy and varied diet. EVIDENCE: Some of the people living at Bridgewood House have regular day services that they attend. For those that do not, staff at the home are responsible for keeping people occupied. During the inspection, it was noted that people spent long periods of time in front of the television without any other activity being offered. In one lounge, people were unable to see the television as a table had been left in the way. When asked, staff reported that there was no agreed activities timetable and that no activities had been arranged for that afternoon as people did an activity the day before. It was positive that a Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 13 member of staff offered some of the ladies a manicure, which they appeared to enjoy. Staff reported that, when they get time, they offer games or tabletop activities to people but staff on duty at the time of inspection had very little time to spend sitting and interacting with people. The acting manager has since reported that a newly appointed senior member of staff has been given the responsibility of looking at activities for individuals, so it is hoped that this will improve the range and frequency of activities that are offered. Community based activities are arranged on a fairly regular basis and evidence of this was seen in individuals’ daily records and in self-assessment information provided by the home as part of the inspection. There was evidence in individuals’ records that contact with family or friends is supported. During the inspection, one visitor came to the home. The home benefits from having a large lounge and dining room in addition to small lounges on each of the three wings, so there is plenty of space for people to see their visitors in private if they prefer to do so. Staff were observed to respect people’s rights and responsibilities. Staff asked individuals’ permission before entering their bedrooms and knocked prior to entering bathrooms or bedrooms. People living at the home are free to spend time in their own bedrooms, in the lounge on the wings or in the larger communal lounge or dining room. People were observed to choose where to spend their time during the day. Two cooks are employed to work at the home. There is a written record of individuals’ likes and dislikes and of any special diets that the cooks refer to when planning and preparing meals. Individuals are asked what they would like and a choice of meal is always available. Two of the individuals spoken to said that the meals at the home were good. On the day of inspection, the lunchtime meal was sausages, potatoes, Yorkshire puddings and vegetables, followed by fresh fruit and yoghurts. Drinks were provided throughout the meal, and the tables and meals were well presented. Staff were observed to support people with their meals in a respectful and discreet manner. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Medicine management is good. People receive personal support in the way they prefer and require and, generally, people’s health care needs are met appropriately. However, some poor recording and monitoring puts people at risk of harm. EVIDENCE: Those care plans that were sampled contained excellent detail about how individuals prefer to be supported with their personal care. Staff practice when supporting individuals was positive and sensitive, discreet assistance was given. A range of equipment to support people with their mobility is available in the home. In general, people at the home looked well cared for and, as previously mentioned, a member of staff supported some of the ladies to have a manicure. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 15 There is evidence in individuals’ records that regular health care appointments are attended and, in general, individuals’ healthcare needs are met. It was noted in one person’s records, however, that concerns about their wellbeing had not been documented in sufficient detail to enable staff and health professionals to effectively monitor the specific area of concern. This has been discussed with the acting manager. Since the last key inspection, the medication systems have improved significantly. All medications tallied with the records kept, and medication administration records are up to date and accurate. Information is now available about what medication individuals are taking and guidelines are in place providing excellent detail for staff about when ‘as required’ medication should be given. Since the last key inspection, the pharmacist inspector has visited the home and her report is available on request from the Commission for Social Care Inspection. Recommendations made by the pharmacist inspector have been addressed. It was noted, when examining an individual’s record, that an increase in medication for sleep had been arranged. However, records suggested that the individual had not had any significant difficulties with sleeping. The acting manager explained that staff had probably not recorded accurately the individual’s sleep pattern. This is unacceptable practice and puts people living at the home at risk. It is essential that staff keep accurate records so that any changes to individuals’ health or condition can be dealt with appropriately and health professionals are given accurate, detailed information. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are protected from harm or abuse and procedures are in place for dealing with complaints appropriately. EVIDENCE: A clear complaints procedure is in place, and those people spoken to said they knew how to make a complaint. Information provided by the home indicates that no complaints have been received in the last twelve months. A complaint discussed at the last key inspection that had not been dealt with satisfactorily is now closed, as the complainant has decided not to take the complaint any further. Safeguarding policies and procedures are in place and reflect the Department of Health “No Secrets” guidance, and multi-agency guidance agreed with the Local Authority. Staff are aware of these procedures. There is evidence in staff supervision records, that the acting manager has discussed staff responsibilities in respect of protecting individuals from abuse and how to report any suspicions. Information received from the home indicates that one referral under safeguarding procedures has been made in the last twelve months. The local authority has dealt this with and no further action is to be taken. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a comfortable home with plenty of space. However, not all parts of the home are clean and hygienic, and fire doors continue to be wedged open compromising the safety of people living at the home. EVIDENCE: A tour of the premises was conducted, including all communal areas and some bedrooms. The home is comfortably furnished and domestic in style. Although the home is large and offers accommodation for up to twenty-three people, it is split into ‘wings’, which offers small more domestic-type accommodation. There are three wings providing a lounge and small kitchen area, bathroom and bedrooms. This is in addition to three bungalows in the grounds of the home offering semi-independent living. Most parts of the home were clean and free from unpleasant odour. At the time of the inspection, decorators Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 18 were painting the corridors, new light fittings were being fitted to the corridors, and arrangements had been made to have specialist panelling fitted to the bottom half of some walls to protect them against damage caused by wheelchairs. Information received prior to the inspection states that new carpets and curtains have been ordered for the corridors and bedding has also been ordered. Some areas of the home are in a poor decorative state, and the senior on duty reported that there is a rolling programme of re-decoration. At the time of inspection, it was noted that some parts of the home were not clean and hygienic. The staff member explained that the domestic was working her way around the home, however some areas had a build up that had been there for some time. For example, the bathroom in Church View was not fit for use. The shower and bath were both very dirty, and the member of staff said that the shower isn’t used which is why it isn’t cleaned. If an individual wanted to use the shower it would not be possible before heavy duty cleaning due to the unhygienic state it is in. An unpleasant odour was present in two of the six bedrooms that were seen, and the bedding on three of the beds was soiled although they had been re-made. Bath charts were seen on the bathroom walls with records of whether each person had had a bath, shower or wash. This information must not be publicly displayed. If this needs to be recorded, it must be on individuals’ records. Staff record the temperature of the bath each time it is used. None of the temperatures recorded were above 40°C and, on some occasions, people were having a bath at 38°C. The recommended temperature is 43°C and action must be taken to increase the water temperatures at the home. A shared bedroom did not have a privacy screen or curtain and this needs to be provided so that the people sharing the bedroom can have some degree of privacy if they choose to do so. Despite being raised with the home at the previous two inspections, fire doors continue to be wedged open. This does not demonstrate that fire safety is being taken seriously at the home and steps must be taken by the management to ensure that safe working practice requirements are complied with. Bridgewood House has a system whereby, if the fire alarm or burglar alarm is activated in any of the Bridgewood Trust homes, it is activated at Bridgewood House and a printed record is received at the home of where the alarm has gone off. At the last key inspection, it was noted that this causes distress to at least one person and has a negative impact on several people who live at the home due to the extremely loud noise of the alarm. This was particularly distressing on a Monday when all the Trust homes test their alarm systems, resulting in the alarm at Bridgewood House being activated over and over again. Since the last key inspection, arrangements have been made to silence the alarm at Bridgewood House during testing at the other homes. An additional member of staff is on duty to deal with the alarm system and Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 19 receive the printed records of where the alarms have been activated. This is reported to be a relief to people living and working at the home. However, at all other times, if the alarm goes off at another home, this still sounds at Bridgewood House. The acting manager has since informed CSCI that alternative arrangements are being explored so that the alarm at Bridgewood House only sounds if there is an emergency at the home. The Bridgewood Trust should keep the CSCI updated of progress in this area. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A skilled staff team supports the people living at Bridgewood House and, although recruitment practice is generally good, tightening up of procedures would improve the quality of service in this area. EVIDENCE: Staff on duty at the time of the visit were observed to have positive relationships with people living at Bridgewood House. Staff were aware of individuals’ needs and interacted with people in a positive and respectful manner. Information provided by the acting manager in the self-assessment states that 71 of staff are trained to NVQ level two or above. This is above the recommended 50 of all care staff having an NVQ at level two or above set out in the National Minimum Standards. Staff training records confirmed that Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 21 staff have received training relevant to their work, and this was found to be mostly up to date. Recruitment records for the three most recently recruited members of staff were examined. Most of the required information was in the files that were seen although there were some gaps. For example, the sheet that contains details of dates of employment was not available in two files making it impossible for the inspector to establish whether any gaps in employment had been adequately explored. The records relating to two staff who had previously worked in a different role for the Bridgewood Trust were among those records that were examined. It was found that, in both, the second reference was missing. Although references had been taken up for their previous roles, it is still essential that the required references be obtained for the new positions, as these are more senior. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory quality assurance systems are in place, however the health and safety of people living at Bridgewood House needs to be better protected in some areas. EVIDENCE: The home is run by an acting manager who has worked in a senior role for the Bridgewood Trust for several years. The acting manager has applied to the CSCI to become the registered manager. Although the acting manager has not completed the registered managers award, she has informed the CSCI that she will be enrolling for this training soon. Staff and people living at the home Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 23 reported that the manager is approachable and supportive and all reported having a positive relationship with her. There are some areas that require improved management and leadership. For example, where concerns have been identified about the monitoring of an individual’s health and subsequent increase in medication, there was an unacceptable lack of awareness of what should be monitored and how this should be achieved. Since the inspection, support from the community learning disability nurse has been provided to the manager to assist in improving practice in this area. The organisation uses a formal quality assurance system and, in addition to this, people using the service and their relatives are asked to complete satisfaction surveys annually. Individuals are consulted about how they view their care prior to reviews being carried out. Evidence of this was seen in some individuals’ records. Monthly visits are completed by the provider as required under the Care Homes Regulations 2001 and reports of these visits are provided to the CSCI. Information provided by the home as part of this inspection indicates that safety checks and maintenance of equipment is carried out as required. Records sampled at the time of inspection confirmed this. Fire safety checks are carried out as required and regular fire drills are conducted. Good records are kept listing all those people involved in the drill. The practice of wedging fire doors open continues to be picked up during inspections. The acting manager must address this with the staff team and take the necessary action to comply with relevant regulations. Where it is identified that fire doors need to be kept open, automatic closures must be fitted. As previously mentioned in this report, the health and safety of people living at the home needs further protection in some areas. This includes monitoring of an individual’s wellbeing including keeping accurate and detailed records, ensuring hot water is delivered at a temperature of 43°C, or close to this, in baths or showers used by people living at the home and improved infection control practice. Bridgewood House DS0000026322.V355652.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 2 X 3 X X 1 X Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 25 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 YA10 Regulation 17(1)b Requirement Timescale for action 31/12/07 2. YA19 12(1)a,b 3. YA24 YA42 23(4)a Records relating to people in the home must be kept securely to protect people’s privacy. This includes ‘bath lists’ which record what personal care people have received and are currently displayed on bathroom walls. 15/01/08 So that individuals’ health and welfare is properly monitored and their needs met appropriately, staff must keep accurate and detailed records. Systems must be in place so that the manager or senior team monitors records so that significant changes are picked up or poor record keeping is identified at the earliest opportunity. In order to ensure the safety of 31/12/07 people living at the home, the practice of wedging fire doors open must cease. (Previous timescales 30/08/07, 30/09/07 unmet) Continued failure to comply with this requirement will lead to enforcement action being taken. Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 26 4. YA24 YA30 16(2)j 5. YA24 16(2)c 6. YA34 19, Schedule 2 (3)(6) So that people are living in a pleasant and hygienic environment, suitable arrangements need to be made to ensure satisfactory standards of hygiene and cleanliness are maintained. This includes providing clean bathrooms, clean bedding and clean toilets. Where individuals have to share bedrooms, privacy screens need to be offered and provided if required. Two written references and a full employment history, together with a satisfactory written explanation of any gaps in employment, must be available in respect of all employees. This is to ensure the protection of vulnerable people living at the home. 31/12/07 31/01/08 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations To ensure that errors are not made and all staff understand records that they have to read/keep, abbreviations should be avoided. However, where it is necessary to use abbreviations, a key for all codes used needs to be available to ensure that everybody understand what the record means. Hot water temperatures should be maintained close to 43°C. This will ensure that showers and baths are taken at a safe and pleasant temperature. Action needs to be taken to eliminate the unpleasant odour in some parts of the building. 2. 3. YA24 YA42 YA30 Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Bridgewood House DS0000026322.V355652.R01.S.doc Version 5.2 Page 28 - 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!