Inspection on 03/11/05 for New Bradley Hall

This inspection was carried out on 3rd November 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

New Bradley Hall 07/02/08

New Bradley Hall 02/11/06

New Bradley Hall 19/10/04

New Bradley Hall 10/05/04

New Bradley Hall 26/01/04

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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 Mike Kirton Unannounced Inspection 3rd November 2005 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 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.V263128.R01.S.doc Version 5.0 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) 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.V263128.R01.S.doc Version 5.0 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 Metroplolitan Borough Council and the National Care Standards Commission. By the 31 September 2003, water available from bedroom/bathroom taps together with any exposed pipeworks 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. 2nd June 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 sited 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. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 7 hours by Mike Kirton and Linda Brown. Discussions took place in the two main lounge areas and 14 residents were spoken to individually. Informal discussions took place with the staff on duty and 4 visitors to the home. 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? 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. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 6 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.V263128.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion. For further information please read the report dated 2nd June 2005. EVIDENCE: New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion. For further information please read the report dated 2nd June 2005. EVIDENCE: New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion. For further information please read the report dated 2nd June 2005. EVIDENCE: New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 The home has sufficient procedures in place to ensure that complaints are dealt with effectively and residents are protected from abuse. Further steps are needed to ensure all procedures are implemented and reviewed. 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. Since the last inspection there has been 1 complaint, which has been investigated, and 1 compliment. Residents met during the day said they would speak to their relative, staff member or manager should they be concerned about any aspect of their care. The home has an adult abuse protection and whistle blowing policy in place, which along with all others should be signed and dated by the manager and evidence provided that staff have read and understood them. All staff questioned about these procedures were aware of their responsibilities and would report any concerns of abuse to their manager. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not fully assessed on this occasion. For further information please read the report dated 2nd June 2005. EVIDENCE: New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Although staffing levels are not always met the home was very clean and tidy, and all residents were being well cared for. There is a friendly and homely atmosphere at New Bradley Hall. Staff are very experienced and have a good knowledge of the residents needs. EVIDENCE: In addition to the manager, senior, cooks and domestic staff the home aims to have 6 care staff on duty during the morning and 5 in the afternoon and evening. During the night there are 2 care staff on duty. The rota was examined. This was difficult to follow due to the number of changes made and cover that had to be arranged. On the morning of the inspection the home was 1 staff short due to escorting a resident to hospital. There were also other days where they fell short of their targets. All staff are employed by the Local Authorities Social Services Department and are required to follow their recruitment procedures. Records belonging to 2 staff members recently appointed were examined. These contained a completed application form and employment history, health checklist, 2 references, criminal records check, and proof of identification. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 13 The home has a recruitment and induction policy, but this needs reviewing and updating along with all other documents. 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 67 are now qualified to level 2 NVQ in Care. There was however no evidence available to demonstrate that these standards were being met. Staff met during the day confirmed that they have opportunities to attend training throughout the year. They spoke highly about the home and were happy working there but acknowledged that it was hard work at times. Feedback received from residents included comments such as ‘staff are very good’, ‘they all talk to me even when they are busy’, ‘the girls are very nice’, and ‘I could not have chosen a better home’. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The manager is very knowledgeable about the needs of the residents and has a positive and open approach. Appropriate steps are taken to ensure the health and safety of residents is protected. EVIDENCE: Linda White has many years experience working in social care, as a manager of homes for elderly people, and has the required qualifications. Many of the outstanding requirements have been difficult to implement due to the organisational structure of the social services department i.e. changes to policies and procedures, quality assurance, staff training and implementation of new care plans. There have also been difficulties with the recruitment and retention of staff and there being no deputy to act in her absence. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 15 Information required for the quality assurance monitoring system has been obtained by the social services department but not yet published. An annual development plan will also need to be implemented to improve on the standards assessed. Feedback forms for residents and visitors to the home are available on the information table just through reception. 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. An audit was recently undertaken to ensure accuracy is maintained. The health and safety records were examined and found to be in good order. All fire fighting equipment is serviced annually; the home has a fire risk assessment, and undertakes fire training for all staff twice a year. A 5-year electrical wiring, gas landlords, and portable electrical equipment certificate were seen along with service records for all equipment. New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 16 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? NO 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 OP2 Regulation 17(2) Requirement All service users must have a contract if privately funded or a statement of terms and conditions. The service users or their nominated representative must sign all contracts. These are outstanding requirements from 19th October 2004. The Manager must continue to develop the homes care plans to meet the required standards. These must be reviewed monthly. These are outstanding requirements from 19th October 2004. Records must be maintained for all medical appointments including GP, opticians, chiropodist, hearing, dental, and any specialist treatments. These should show the last appointment and when the next is due. Risk assessments must be completed with all service users including nutrition, falls, and pressure sores. DS0000039054.V263128.R01.S.doc Timescale for action 01/01/06 2 OP7 15(1) 01/12/05 3 OP8 12,13,14 01/12/05 New Bradley Hall Version 5.0 Page 18 4 OP9 13,18 5 OP30 18,19 6 OP33 24 7 OP36 18(2) 8 OP38 12,17,24 These are outstanding requirements from 19th October 2004. To provide appropriate training to staff who administer medication. Medication must be administered correctly without any errors on the record sheet. Residents must agree to have medication administered on their behalf unless agreed otherwise following a risk assessment. Care plans must be developed for all medications which are only to be administered as needed. These are outstanding requirements from 19th October 2004. Medication must be administered correctly. Staff must observe that the medication has been taken before signing the record sheet. Evidence of staff training and induction must be available to demonstrate that the minimum standards have been met. The results from the quality assurance system must be published on a annual basis and a action plan implemented to improve on the standards. All care staff must be supervised at least six times per annum. These are outstanding requirements from 19th October 2004. Ensure that all the required policies and procedures are available and reviewed each year or as required. These should be dated and signed by the manager. Staff should also sign to say they have been read and understood. Ensure that all policies and DS0000039054.V263128.R01.S.doc 03/11/05 01/01/06 01/03/06 01/01/06 01/03/05 New Bradley Hall Version 5.0 Page 19 9 OP38 23 10 OP38 26 procedures are available in formats that make them accessible to service users. These are outstanding requirements from 19th October 2004 Fire doors must not be wedged 03/11/05 open and must shut fully into the frame. These are outstanding requirements from the last inspection. The Responsible Individual must 01/12/05 send monthly reports to the Commission. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations New Bradley Hall DS0000039054.V263128.R01.S.doc Version 5.0 Page 20 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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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