Inspection on 02/11/06 for New Bradley Hall

This inspection was carried out on 2nd November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

New Bradley Hall 07/02/08

New Bradley Hall 03/11/05

New Bradley Hall 19/10/04

New Bradley Hall 10/05/04

New Bradley Hall 26/01/04

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Maple Lodge

Heathlands

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Breme

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Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE New Bradley Hall Compton Drive Off Stream Road Kingswinford West Midlands DY6 9NP Lead Inspector Chris Lancashire Key Unannounced Inspection 2nd November 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Bradley Hall Address Compton Drive Off Stream Road Kingswinford West Midlands DY6 9NP 01384 813515 01384 813516 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) N/K Dudley Metropolitan Borough Council Linda Elizabeth White Care Home 31 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (27) of places New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 20 January 2003 are met within the timescales contained within the action plan agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. By the 31 September 2003, water available from bedroom/bathroom taps together with any exposed pipe works should not exceed 43 degrees Celsius. In the interim, following risk assessments, strategies are implemented to safeguard service users. The home currently accommodates one service user in the category of MD and one in the category of PD. These categories will remain until such time that the identified service users placements are terminated. 3rd November 2005 2. 3. Date of last inspection Brief Description of the Service: New Bradley Hall is a local authority home registered to provide 24-hour care for 31 people over the age of 65, including 4 people with a diagnosis of dementia and 2 respite beds. Originally built in the mid 1960s it has been refurbished to improve the facilities and services available. This now includes 31 single rooms, all with ensuite (toilet and shower facilities) and a number of smaller sized lounge/dining areas. There is a range of aids and adaptations including hoists, vertical lift, call system, wide doorways, corridors, handrails, and spacious bathing/toilet facilities. The home is in its own large grounds near the centre of Kingswinford, easily accessible by public transport. The property is surrounded by an established residential area, but is well screened from nearby houses. The fees for this home are £355.00 per week. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over an eight hour period, over two days. One the second day, the inspector was accompanied by a colleague, Linda Brown. Prior to the inspection, the manager provided information about the home. Nine residents and ten relatives provided responses to questionnaires about the quality of life in the home. Discussions took place with residents in the two main lounge areas. Informal discussions took place with staff and three members of staff were interviewed in addition to on of the home’s doctors. The manager assisted in the inspection process. The care records for 3 residents and 2 staff files were examined along with other documents as needed. What the service does well: What has improved since the last inspection? The manager has made efforts to address the requirements of the last report. All newly admitted residents now have contracts, as do the majority of those already at the home. There is a new system for care planning and risk assessments. The home also has a system of reviewing one plan each day, so that there are monthly reviews on all residents. There are clearer systems for recording medical needs and appointments. Staff have received further training in the administration of medication. Work is taking place to review the quality assurance system. Care staff are now receiving more frequent supervision. The policies and procedures are available on the intranet and application can be made to obtain these in a variety of languages, including Makaton. The manager has requested electronic door closures, to alleviate the fire risk posed by propping doors open. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. There are good admission procedures in place to ensure that prospective residents’ needs can be met and that they are able to make an informed choice before making a decision to move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose and service users’ guide, along with a copy of the latest inspection report is kept on the visitor’s information table. These documents have been reviewed and updated recently and are made available on request to prospective residents and their relatives. This information also includes the complaints procedure and advocacy contact details. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 9 The manager described the process for providing this information in a range of languages and formats and this would be arranged to meet the needs of the person making the enquiry. This system is more economical than maintaining large stocks of leaflets in different formats and it means that individual needs can be met. A separate folder is maintained where all referrals and records leading up to an admission are kept. A full assessment is carried out by the home in addition to the information received from other professionals involved. Opportunities are made available for trial visits to be made. Staff and residents described the admission process. Staff were clear about the needs which they could meet and those which would require more specialist intervention. Sampled files contained details of the pre-admission assessment, together with copies of letters assuring prospective residents that their needs could be met. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Residents’ needs are recorded and plans show how they will be met. Residents’ health needs are met and they feel that their privacy and dignity are respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is using a new system for recording care plans and risk assessments. The home also has a system of reviewing one resident’s plan each day, so that there are monthly reviews on all residents. The manager is pro-active in ensuring that residents’ statutory reviews with the social worker also take place. However, in a small number of cases, these have not occurred. There is evidence that the manager has made repeated requests for these to b arranged. Sampled plans were suitably detailed and staff were aware of the contents. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 11 The staff complete nutritional assessments on each resident and maintain records of their weight. Sampled records contained these charts. However, care needs to be taken to ensure that the height of the residents is also recorded, in order to determine optimum weight. The home has improved systems for recording medical needs and appointments. The inspector spoke with a visiting doctor who informed her that she visits weekly and staff accompany her on her rounds. The surgery also holds weekly meetings for the homes on its list and these include speakers such as continence advisors and mental health specialists. Other health professionals visit the home on a regular basis, including opticians, dentists and a podiatrist. Staff have received further training in the administration of medication since the last inspection. Sampled medication records were found to be appropriately completed. Medication was seen to be stored appropriately, with a monitored dosage system being used. This is overseen by a pharmacist. There are suitable arrangements for the storage, administration and recording of controlled medication. Residents confirmed in responses to questionnaires and in person, that they are treated with dignity and their privacy is respected. Staff comments and observations of staff in the course of their duties reflected this approach. Two relatives commented that the staff always make an effort to ensure that their relatives are presented in a dignified way. Residents’ clothes appeared to be well cared for. The services of a visiting hairdresser are used in a suitably equipped room. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. The home operates flexible visiting arrangements where residents are free to receive visitors. Residents are satisfied with the lifestyle in the home and they are encouraged to make choices about how they spend their time. There is a good variety of meals available daily allowing for choices to be made. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are enabled to participate in a variety of activities according to their preferences. These include bingo, playing musical instruments, sing-along and parties. Those who wish to participate do light gardening and potting plants. There are regular coffee mornings, fundraising events, such as a recent harvest festival auction and celebrations of festivals. Library books are available and there are games such as dominoes. Clothes sales and visits from the hairdresser also help to provide stimulation. Trips outside the home include shopping, the glass museum, pub meals, garden centres and theatre visits. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 13 Church services are held inside the home and some residents attended the church harvest lunch. Residents who spoke with the inspector particularly enjoyed the occasional visits of singers to the home. They also said that they enjoyed times when staff could sit and chat with them. Residents confirmed that they are encouraged to make choices about their lives and how they spend their time. Staff described their role in discussing preferences with residents. As information is gathered about preferences, this is added to the residents’ notes. Residents choose when they get up and go to bed, with some choosing to stay up until midnight and others going to bed before nine o’clock. Relatives reported that they were able to visit at any time but would inform the home if they would be very late or early. Residents may entertain their visitors in the communal rooms or their bedrooms. There is also a small room on the ground floor for this purpose. Information is kept on the visitors’ table and/or notice boards around the home to keep everyone updated with what is going on and visitors are made welcome at events and celebrations. Visitors are asked to sign a book to indicate their presence in the home. A varied menu is provided. At breakfast, cereal, toast and a full cooked breakfast are available, there is a choice of two main midday meals and choices at tea time. Jacket potatoes and sandwiches are available for those choosing not to eat a main meal. Snacks and drinks are available at all times. The menus take into account personal preferences and dietary requirements and appear to be well balanced. Residents confirmed that they are happy with the food. Several residents, who had low weights prior to admission, have gained weight since coming to the home. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home has sufficient procedures in place to ensure that complaints are dealt with effectively and residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is clearly displayed around the home. In order to comply with the required standards and legislation the manager has provided further information in addition to the Social Services procedure, which includes contact information for the Commission for Social Care Inspection. All of the people who provided comments to the inspectors indicated that they knew how to make a complaint. However, many commented that the staff and manager are approachable, so they would make informal comments directly. No complaints have been referred to the Commission for Social Care Inspection in relation to the home during the past year. The home has received three complaints directly, only one f which was partly substantiated. The home has an adult protection and whistle blowing policy in place. All staff questioned about these procedures were aware of their responsibilities in this respect and would report any concerns of abuse to their manager. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Although New Bradley Hall is a fairly large home it continues to maintain a homely atmosphere, is nicely decorated and well furnished. Good procedures were in place to reduce the risk of cross contamination and hygiene levels were being kept to a high standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All communal areas of the home were inspected along with several individual bedrooms. These were all found to be clean, tidy, well maintained with no bad odours detected. One empty bedroom had recently been decorated prior to a new admission. All bedrooms have en-suite facilities. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 16 There are appropriate procedures for handling food in the kitchen, including the monitoring of fridge, freezer, and cooked meat temperatures. The laundry room was also very clean with systems in place to prevent cross contamination including machines with sluice cycles, separate bags for soiled washing, and identified cleaning equipment. At the previous inspection, the inspector raised the matter of doors being propped open and the possible fire risk. The manager has ordered electronic closures. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. Residents are protected by the home’s recruitment and selection practices. Their needs are met by the staff, who are trained and competent. However, it is difficult for staff to maintain the high standards and to receive adequate formal supervision, due to the dependency of residents and the sickness levels. It is recommended that the manager should review the staffing levels. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home follows the recruitment and selection procedures of the local authority and these ensure that suitable checks are made on each member of staff. References are obtained and employment is subject to induction and a probationary period. The records relating to three members of staff were examined. Once appointed, staff receive supervision and opportunities for training. The records and conversations with staff revealed that although the frequency of supervision has improved since the last inspection, it is difficult to maintain at this level, due to the need to attend to residents. Staff explained that the needs of the residents would always be their first priority and that, should there be staff shortages due to sickness or training, supervision may need to be postponed. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 18 All reported good access to the manager and senior staff, should they have a problem or need to discuss the care of a resident at short notice. Examination of the rotas showed that, although the full staffing complement for the home meets the hours recommended by the guidance, there has been sickness, which has resulted in 13 agency staff working for various periods during the past 8 weeks, covering 77 shifts. There have been particular shortages of night staff and the manager was in the process of recruiting to a night worker post. Staff are clearly working under pressure to maintain the high level of service to the residents. Staff follow an induction pack, which they keep and attend 2 days training. They also have an individual training plan which highlight any gaps which need meeting. The inspector was also informed that 72 are now qualified to level 2 NVQ in Care, with 12 holding a current first aid certificate. Staff confirmed that they have opportunities to attend training throughout the year. This has included infection control, abuse awareness, manual handling, risk assessment, care planning, nutrition, data protection and medication. Planned training includes food hygiene refresher training, supervision and visual impairment awareness. A new training pack concerning falls has been developed. Staff spoke highly about the home and were happy working there but acknowledged that it was hard work at times. Feedback received from residents and relatives included the following; ‘overwhelmed by the kindness shown by all of the staff’….‘ Staff have a good knowledge of x’s needs and have a good relationship with her’. . New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is good. The home is run in the best interests of the residents, by a manager who is well able to discharge her responsibilities. The financial interests of the residents are safeguarded and their health, safety and welfare is promoted. This judgement has been made using available evidence including a visit to this service. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 20 EVIDENCE: Linda White has many years experience working in social care, as a manager of homes for elderly people, and has the required qualifications. She has ensured that progress has been made in relation to the areas of improvement which were required in the last report. There are several mechanisms for quality assurance within the home. Feedback forms for residents and visitors to the home are available on the information table just through reception. More structured questionnaires have been developed as part of a more formal system of quality assurance. These include a service user satisfaction survey, a staff survey and one survey for relatives and other stakeholders. This has not yet been piloted. The home has audit systems for property issues and falls within the home. There is a weekly medication audit and there are reviews of the residents, which the home is pro-active in requesting. The manager is developing a system of audit which follows the National Minimum Standards. The manager also attends meetings with other managers in the borough and discusses practice and management issues. A report of a recent visit by a representative of the provider has been received by the Commission for Social Care Inspection. However, these visits and reports should be on a monthly basis. Mention has been made in the previous section of the arrangements for staff supervision. The frequency of supervision has improved since the last report was written. However, the pressures on the staff team’s time and their need to prioritise time with the residents means that the frequency of formal supervision is not as high as it should be. Finances are managed by the resident, their relative, or through an appointee. Small amounts are held by the home for safekeeping. Any withdrawals or deposits are signed by 2 staff members and a receipt is kept. Audits are undertaken periodically to ensure accuracy is maintained. The home maintains records of the servicing and maintenance of services to and equipment in the home. Sampled records were found to be up to date. Risk assessments are completed in relation to the environment and hazardous tasks and suitable records are maintained in respect of the storage and use of hazardous substances. New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 x 2 New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 7. Standard OP36 Regulation 18(2) Requirement All care staff must be supervised at least six times per annum. This is an outstanding requirement from 19th October 2004. There has been some improvement in this area. 10. OP38 26 The Responsible Individual must send monthly reports of visits to the home to the Commission for Social Care Inspection. 01/02/07 Timescale for action 01/02/07 New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 23 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 OP19 Good Practice Recommendations Consideration should be given to the provision of additional car parking space. It is recommended that the manager should review the total numbers of staff, taking into account the increased dependency of residents. 2 OP27 New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 New Bradley Hall DS0000039054.V316613.R01.S.doc Version 5.2 Page 25 - 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!