Inspection on 30/08/07 for Bridgewood House

This inspection was carried out on 30th August 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 no outstanding requirements from the previous inspection report, but made 5 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 28/11/07

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 30th August 2007 9:45 Bridgewood House DS0000026322.V343173.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.V343173.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.V343173.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) Bridgewood Trust Limited Mrs Tracey Hall 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.V343173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 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 four 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.V343173.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted by one inspector between the hours of 9.45am and 5.45pm. Since the last key inspection carried out in March 2007, the registered manager has left and an acting manager has been appointed. It is intended that the acting manager will apply to the Commission for Social Care Inspection (CSCI) to become registered. As part of this inspection, information has been used that has been provided by Bridgewood Trust at the request of the CSCI about the service, the people who live there and the staff that work there. The CSCI also sent out surveys to, and received responses from people living at the home, their relatives and a local doctor. Other evidence and information used has been received through notifications from the home. 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 examined menus and records of food provided and conducted a tour of the premises. As part of the inspection visit, the inspector had discussion with the acting manager, the cook, care staff and four people living at the home. Feedback from people living at the home was positive. In view of the fact that a number of 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. One survey was returned from an individual living at the home, indicating overall satisfaction with the care that they receive. Relatives of people living at Bridgewood House completed three surveys. Most comments received were positive and expressed satisfaction with the care their relative received at the home. Comments received include, “Bridgewood House is a very well run home with caring staff and feels like home as you go in the front door”, “We are more than satisfied with the Trust”, “Very friendly and supportive. Always clean and cheerfully decorated. Holidays, activities and outings are arranged”. The inspector would like to thank everyone for their assistance and hospitality during the inspection process. What the service does well: People’s needs are assessed prior to them moving into the home. People are offered good support to make some choices about their lives. People living at Bridgewood House have active lifestyles. Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 6 Good support is given to ensure people remain in touch with family and friends. A healthy diet is offered. Good personal support plans are in place so that staff are clear about how to support people in this area. Staff have positive relationships with the people living at the home and communicate effectively with people they are supporting. Bridgewood House is a clean and comfortable home with plenty of space. More than 50 of the staff team have a qualification in care. The acting manager is approachable and supportive. What has improved since the last inspection? What they could do better: Identified risks to people living at the home need to be assessed properly and clear guidance must be agreed about how to minimize risks to individuals. Practice regarding the management, administration and recording of medication needs to improve so that people’s health and well-being is better protected. Staff need to develop a better understanding of why people are taking their prescribed medications so that they can more easily monitor the effectiveness and possible side effects. The home needs to learn from previous mistakes in how they deal with complaints from people living at the home. Complaints need to be taken seriously and appropriate actions taken in response. Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 7 The home needs to explore alternative arrangements for the fire and burglar alarm systems within the Bridgewood Trust as each time an alarm goes off in one of the other homes, it also sounds at Bridgewood House. This is very intrusive for the people living at the home. Some of the bedding is very worn and needs replacing. Staffing levels need to be reviewed making sure that there is always enough staff on duty to meet individuals’ needs in a timely fashion. 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. Bridgewood House DS0000026322.V343173.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.V343173.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. Peoples’ needs are assessed before they move into the home so that staff are aware of individuals’ needs and aspirations. EVIDENCE: Records examined contained evidence that individuals’ needs are assessed prior to them being admitted to Bridgewood House. 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.V343173.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. People living at the home are supported to make choices about their lives, have a care plan containing good information about how to meet their needs, and identified risks to people are generally assessed and there are agreed ways to minimise risks. EVIDENCE: Records relating to three individuals were examined as part of this inspection. All contained information about how the individuals’ needs should be met using a person centred approach. Although there was lots of useful information, this was not organised in such a way that it is easy to find, however the acting manager explained that revised systems were to be implemented that would address this. It was noted that there was no information in individuals’ records explaining why medication had been prescribed. This would be useful in helping staff to monitor whether peoples health needs are being met. This is discussed in more detail under standard 20. There is evidence in the records Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 11 that individuals’ care plans are reviewed every six months. Those relatives that completed a survey as part of this inspection confirmed that they are invited to attend the reviews. Risks to people living at the home have been assessed and agreed actions to minimise the risk recorded. Further development of some of these is necessary in that it is not always clear why something is deemed to be a risk to an individual. One risk assessment seen was inappropriate and not based on any evidence of an actual risk. This was discussed with the acting manager at the time and has also been discussed with the chief executive of the Bridgewood Trust. Throughout the inspection visit, most staff were observed to support individuals to make choices about their lives, including, what they would like to eat, drink, activity they would like to do or which part of the home they would like to spend time in. One person who lives at Bridgewood House returned a survey and confirmed that they are offered choices about many aspects of their life. Bridgewood House DS0000026322.V343173.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 are supported to lead active and fulfilling lifestyles, have their rights respected, keep in touch with family and friends and have a varied and nutritious diet. EVIDENCE: Information received prior to the inspection indicates that people living at Bridgewood House take part in a range of social, leisure and educational activities both in and outside of the home. This was confirmed in daily records that were examined. On the day of inspection some people were out at day services, craft centre or at work (paid or voluntary). For those people at home for the day, entertainment was arranged in the home. A singer and keyboard player visited the home and people appeared to enjoy taking part in this activity. People living at the home that spoke with the inspector confirmed that they have active lifestyles and reported enjoying the holiday they had Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 13 been on this year. A relative commented in the survey that holidays, activities and outings are arranged for the people living at Bridgewood House. Records indicate that people are supported to stay in touch with family and friends, and feedback from relatives in the survey supports this. Surveys completed all confirmed that relatives are kept informed of important matters affecting their relative and that good support is offered in keeping in touch. During the inspection, staff were observed to respect peoples’ rights, for example, staff knocked on bedroom and bathroom doors before entering, offered choices and then and respected those choices made by individuals and most staff interacted in a positive manner with people living at the home, and not exclusively with each other. Two cooks are employed to work at the home, and the inspector had the opportunity to meet with one cook who had only recently started work at Bridgewood House. Menus were seen, and there was evidence that a varied and healthy diet is offered to people. The cook explained that there is always a choice of meal, and evidence of this was seen in the records and during the lunchtime meal. The inspector joined people for lunch, and observed that the food was well presented, fresh and healthy. Tables were nicely laid with tablecloths, condiments and napkins, and in general staff were seen to offer discreet assistance whilst supporting people with their meals. Bridgewood House DS0000026322.V343173.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 poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they prefer and require, however some peoples health is at risk due to the poor and unsafe practice in respect of medicine management at the home. EVIDENCE: Clear information is available in individuals care plans about how they prefer to be supported with their personal care. In general, staff were observed to offer discreet assistance ensuring that peoples dignity and privacy was respected. Feedback from a GP as part of the inspection process indicates that the GP is satisfied with the overall care provided to people living at the home. It was noted however that staff do not always bring full details that are relevant to individuals when visiting the GP. This must be addressed by the home. There was evidence in the records that people are supported to attend healthcare appointments as necessary. It was concerning however that staff spoken to did not have a clear understanding of individuals’ conditions and why they had been prescribed specific medications, and this information could not be found in the records. Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 15 Medication and records were sampled and although day to day medication was in good order and the records were satisfactory, a number of serious errors had been made regarding the administration of ‘as required’ (prn) medications. It was found that staff had been administering medication that was prescribed as a prn medication on a daily basis. The records showed that this had been happening for over three weeks, however previous medication administration records were not checked so it may have been occurring for considerably longer. There was no information in the individuals’ records about why they were taking these medicines, and staff spoken to did not know. Staff were also unable to explain why they were giving this medication every day and no guidance about under what circumstances these medicines should be given was in place. It was also noted that staff had not followed the policy and procedure in respect of the recording of controlled drugs, and this was discussed with the acting manager at the time. Additionally, no guidance was in place for staff regarding what to do if an individual was still in bed when his medication was due to be administered. A staff member explained that she would wait for a few hours and then wake the individual to take the medication, however there was no agreed strategy and no evidence that any advice had been sought from the GP. The practices described are unsafe and puts people at Bridgwood House at risk of harm. Following the inspection, a letter expressing serious concerns was sent to the provider asking that they put right this matter within specified timescales. The provider has since responded to the letter outlining steps they are taking to address the concerns raised. Bridgewood House DS0000026322.V343173.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 adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures for the protection of people living at the home and complaints have been improved and are satisfactory, however peoples’ complaints are not always acted upon appropriately. EVIDENCE: A complaints procedure is in place that has been revised since the last inspection to include timescales for action. Feedback from relatives and an individual living at the home suggests that people are aware of the homes complaints procedure. It was identified at the last inspection that a complaint received by the home was a safeguarding matter (concerning an allegation of potential abuse). Further exploration of this matter was made following the last inspection as the home had not followed local safeguarding procedures in dealing with this, instead they had investigated the matter themselves and only then informed the Local Authority and the Commission for Social Care Inspection. Records of the investigation have now been examined and serious concerns about how the investigation was conducted have been raised with the provider. The records did not demonstrate that the individual’s complaint had been acted upon or dealt with appropriately and an inappropriate risk assessment has been put into place as a result of the investigation. This was discussed with the acting manager at the time of the inspection and has since been discussed with the chief executive of the Bridgewood Trust. This matter is now with the Local Authority to re-visit the original complaint with those Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 17 involved. Information received prior to the inspection indicates that no complaints have been received at the home in the last twelve months. Following concerns about safeguarding policy, practice and procedures within the Bridgewood Trust, safeguarding policies and procedures have been revised and now reflect the Department of Health “ No Secrets” guidance, and multiagency guidance agreed with the Local Authority. All staff at the home are reported to have received briefing about the revised procedures, and evidence of this was seen in staff records that were examined. Staff spoken to also confirmed this and demonstrated an awareness of good practice in this area. Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 18 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 clean and comfortable environment, however some bedding provided needs replacing, some areas need to be decorated and in order to keep the environment safe, fire doors need to be kept closed. EVIDENCE: As part of the visit, a tour of the premises was conducted. This included all communal areas and a selection of individuals’ bedrooms. All areas of the home were clean and free from unpleasant odour. 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 semiindependent living. It was noted that wallpaper was peeling off in a bedroom and the lounge on Church wing. The senior carer explained that this was due to difficulties with the guttering outside the building and reported that there Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 19 had been several attempts to resolve the problem. This needs to be investigated further. During the tour, it was noted that the bedding in some rooms was in a poor state. Some sheets were thread bare, and some mattress and pillows were covered in plastic sheeting, with only a sheet or pillowcase over the top. If it is necessary to make mattresses and pillows waterproof, more comfortable alternatives should be explored. The acting manager acknowledged that the bedding was in need of replacement and had already identified this as a matter requiring action. It was noted that the fire door leading to the laundry had been wedged open and the senior staff member was asked to remove the wedge at the time of the inspection. The home must not wedge fire doors open as it puts people living at the home at risk; this was also brought to the managers attention at the previous inspection and the acting manager must ensure that staff comply with health and safety requirements. In addition to the fire door being wedged open, it was noted that the laundry is accessible to people living at the home. If it is assessed as safe for people to have free access to this area, an assessment of the risks must be completed and all items that could be hazardous to peoples health must be stored securely, for example cleaning fluids/powders etc. 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. The alarm went off during the inspection for another home and it was observed to have a negative effect on an individual who dislikes loud noises and as a result becomes distressed. The acting manager reported that Mondays are particularly difficult as all the homes conduct fire alarm tests, resulting in the alarm at Bridgewood House being activated on many occasions throughout the day. Given the distress this causes for at least one person living at Bridgewood House and the intrusive effect of the alarm, it is recommended that the provider explore alternative arrangements. A number of people living at the home enjoy sitting in the entrance hall, however it was reported that people do not use this area as much on Mondays as the alarm bell is situated there. Bridgewood House DS0000026322.V343173.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): 32,33,34,35 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 people living at Bridgewood House and robust recruitment procedures are implemented to ensure that people living at the home are protected. EVIDENCE: Staff were observed to have positive relationships with people living at the home. Most staff interacted in a respectful manner and people living at Bridgewood House seemed to be comfortable with staff. Those staff spoken to demonstrated a good understanding of the needs of people, with the exception of issues regarding medication (see standard 20). A survey completed by an individual living at the home indicated that staff treat people well and listen and act upon what they say. Additionally, feedback from relatives suggested that the staff meet individuals’ needs. Information received from the home as part of this inspection indicates that of twenty-six care staff, fifteen have a National Vocational Qualification (NVQ) at level two or above (58 ). 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. The acting manager confirmed that all new staff completed the Learning Disability Award Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 21 Framework induction and foundation before going on to complete the NVQ. Staff training records confirmed this. Since the last inspection, the Bridgewood Trust has recruited a training officer that will be identifying training needs and arranging or providing the required training. All staff have received training in safeguarding vulnerable adults since the last inspection. Through discussion with staff and observation it was noted that there are not always sufficient numbers of staff on duty to meet the needs of people living at the home. On the day of inspection, due to staffing shortages, one member of staff was responsible for supporting six people with their morning routines. Staff reported that this could take up until lunchtime on occasions. The needs of the people living at Bridgewood House have increased over the years, as people get older and frailer. It was also found that two people who live in other Bridgewood Trust homes were at Bridgewood House for the day as there were no staff available to support them in their own homes. Both individuals reported that they would much rather be in their own homes, but that they have no choice but to be at Bridgewood House for two days per week. The organisation must review this practice taking into account the needs and wishes of the individuals concerned, the needs and wishes of people who live at Bridgewood House and the numbers of staff available to support the people who live at Bridgewood House in addition to people from other homes requiring support. Staff recruitment records were sampled, and all contained evidence that the required checks had been carried out before staff worked at the home. Records also showed that every member of staff had a recent Criminal Records Bureau check. Bridgewood House DS0000026322.V343173.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 poor 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 and working at Bridgewood House is not always adequately protected. EVIDENCE: Since the last inspection, the registered manager has left the home and an acting manager is in post. The acting manager has worked at Bridgewood House for many years, most recently in the role of senior support worker. The Bridgewood Trust intends to submit an application for the acting manager to become registered by the Commission for Social Care Inspection (CSCI). Although the acting manager has not yet completed the NVQ level 4 or the Registered Managers Award, she reported that she would be enrolling on the Registered Managers Award in the near future. Staff and people living at the Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 23 home said that the acting manager was supportive and approachable and there was evidence of positive relationships. The acting manager was able to demonstrate an awareness of the homes aims and objectives and had a reasonable understanding of the legislative requirements that must be complied with. 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 individual’s records. Monthly visits are completed by the provider as required under the Care Homes Regulations 2001. The acting manager reported that the newly appointed area manager would soon take over responsibility for these visits and the reporting of the visits. Information provided by the home as part of this inspection indicates that safety checks and maintenance of most equipment is carried out as required. Records sampled at the time of inspection confirmed this, however it was noted that portable appliances had not been checked since March 2005; these should be checked annually. However, the Commission for Social Care Inspection has been notified by the home that since the inspection, these tests have been carried out. As previously mentioned in this report, the health and safety of people living and working at the home needs further protection in some areas. Practice in relation to medication is unsafe and puts people at risk of harm. Also, the practice of wedging open fire doors is unsafe and was brought to the attention of the home at the previous inspection. Requirements in relation to health and safety matters have been made as a result of this inspection. Bridgewood House DS0000026322.V343173.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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 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 2 1 X 2 X 3 X X 1 X Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 25 No 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 YA20 YA42 Regulation 13(2)(6) Timescale for action In order to ensure that 12/09/07 individuals living at Bridgewood House have their health and wellbeing protected you must do the following: ensure there are accurate records of all medicines including controlled drugs; ensure the safe administration of medication including ‘as required’ medicines; ensure there is clear guidance in place for the safe administration of prn (as required) medication; ensure there is clear guidance in place in the event of an individual not taking their medication as prescribed; ensure that there is information available to staff about why medication has been prescribed. In order to ensure the safety of people living at the home, the practice of wedging fire doors open must cease. In order to ensure people’s needs are met, there must always be sufficient numbers of staff on duty. 30/08/07 Requirement 2. YA24 YA42 23(4)a 3. YA33 18(1)a 30/09/07 Bridgewood House DS0000026322.V343173.R01.S.doc Version 5.2 Page 26 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 YA24 Good Practice Recommendations Alternatives to the current arrangements whereby fire and burglar alarms activated in other Trust homes also activate the alarm at Bridgewood House should be explored to reduce the intrusion on the people living at the home. A review of the existing arrangements for people from other Trust homes having to come to Bridgewood House because of staffing difficulties at other homes should be conducted. 2. YA33 Bridgewood House DS0000026322.V343173.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.V343173.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. 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