Inspection on 07/02/08 for New Bradley Hall

This inspection was carried out on 7th February 2008.

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

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

Other inspections for this house

New Bradley Hall 02/11/06

New Bradley Hall 03/11/05

New Bradley Hall 19/10/04

New Bradley Hall 10/05/04

New Bradley Hall 26/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

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 Mr Jon Potts Unannounced Inspection 7th February 2008 09:40 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.V348610.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.V348610.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.V348610.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 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 November 2006 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 staff team consists of a Registered Manager who with the assistant of a team of senior staff manages a number of care assistants and domestics. The catering services are contracted in from Dudley Catering services. The fees for this home are £362.00 per week for Dudley residents. Charges would be higher for out of borough placements. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people that use this service experience good quality outcomes. This unannounced inspection took place over two days with the inspector accompanied by an expert by experience on the first day, this a volunteer from help the aged who had a specific focus to look at the residents choice of activities and daily routines balanced against their expectations, as well as the food and accommodation in general. Prior to the inspection, the registered manager submitted a document called an AQAA in which she told us about what the home did well and how they could improve, as well as providing a range of factual information. Four residents and sixteen relatives provided responses to questionnaires about the quality of life in the home. Evidence of the homes performance against a number of key standards was measured through focusing in depth on the care received by three residents, this involving looking at care documents, talking to the residents themselves, staff, management, observation of what was happening in the home and examining a range of other documentation. What the service does well: What has improved since the last inspection? There have been a number of improvements at the home, the following illustrative of the changes made: New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 6 • • • • • There is a new system for the monitoring of resident’s weights that will act as an indicator that there are issues in respect of an individual’s nutrition. In addition menus have been reviewed to reflect the views of residents (such as the provision of more bacon in a morning). Additional equipment to assist with a quick response to falls (such as pressure mats linked into the call system) has been introduced. Based on the comments from questionnaires pre inspection and those at the time of the visit the home has improved the range of activity and stimulation available to residents recently. Residents have easier access to information about the home, this including the complaints procedure, this information available in their bedrooms as well as around the home. Staff training has continued and there are areas where this has been seen to be effective in respect of such as the number of staff that now have a vocational qualification in care. 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.V348610.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.V348610.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): 1,2,3 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their expectations, with their needs are assessed and assurance given that the home can meet these prior to their moving in. EVIDENCE: The home was seen to have a statement of purpose/service users guide that is specific to the individual home and the resident’s living there, clearly setting out the objectives and philosophy of the home. The guide details as to what a prospective resident can expect and gives a clear account of the services provided, quality of the accommodation, qualifications and experience of staff, how to make a complaint and so on. The guide was available in larger print with some pictorial support and the home has access to others within the local authority that can assist with conversion of the statement of purpose/ guide in New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 9 formats, which will meet the capacity of service users. Discussion with a senior indicated that copies of the service users guide are taken out on pre admission visits to prospective residents, this also confirmed in one instance where this was documented on an admission checklist. We also saw that information about the home was readily available around the building at designated points and on notice boards, this readily available to residents and visitors. In questionnaires we received residents told us they received sufficient information prior to admission, with relatives stating they always or usually did, although there was comment stating that information was available on request. We saw the case files for two residents that were admitted to the home during the last 12 months and there was clear evidence within these to show that these residents were involved in the single assessment process (the home having copies of assessments carried out under care management arrangements). The home had also carried out their own assessment at the point they visited the prospective resident at the place they were living prior to admission. The assessment process was judged to be robust and the views and preferences of residents were seen to have been obtained, sufficient to allow the home to commence a service that targeted individual preferences, needs and diversity. Letters were seen on file confirming the outcome of these visits i.e. whether the home was able to meet the individuals needs based on the assessments carried out. All of the senior team and possibly care staff may be involved within these ‘home visits’ so that it is not just the manager that considers the application for residency. The manager spoke to us about the use of questionnaires relating in part to the admission process, information from which was not yet available at the home although was expected in time (as part of information collated by the provider). The manager did see this as one way in which the home would be able to reflect on the views of residents. Residents confirmed to us that they had received copies of contracts, copies of the same seen at the home in individual resident’s files. Only 2 out of the 3 seen had been signed by resident or their representative however. The contracts were seen to be available in larger print and written in easy to understand language covering the range of contractual issues that we would expect to find, including fees and what is not included with this cost. Prospective residents are offered the opportunity to visit prior to admission, with some instances where individuals can have respite stays at the home giving them ample opportunity to ‘test drive’ the service. New Bradley Hall DS0000039054.V348610.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): 7,8,9 & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and dependent on ability play an active role in planning the care and support they receive with assistance from representatives. Resident’s health care needs are supported through the actions of the home and their dignity and privacy upheld. EVIDENCE: We saw that residents had individual care plans in place these summarising the needs, preferences, choices and personal chosen routines of residents in respect of many areas of their day-to-day lives. All three of the care plans examined showed evidence that staff had sought residents views this evidenced following discussion with the residents concerned where they confirmed the accuracy of the same. In addition the majority of the information in the care plans was consistent with information contained within pre admission assessments with the exception of one, this needing some update, as the resident was now more independent, with the plan not New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 11 reflecting their current ability. This plan was, based on the review frequencies seen on all plans, due for update, with reviews carried out usually on a monthly basis. Out of the three care plans we saw only two were signed by residents or their representatives, although as stated we discussed the detail within those not signed with the individual themselves. Residents told us within questionnaires and at the time of the inspection that they received medical support as appropriate to their individual needs, this reflected by documentation. There were however some difficulties finding some of the records of G.Ps visits as these were not always documented in the case file. Personal healthcare needs including specialist health and dietary requirements are fairly well documented each person’s plan and these give a reasonable overview of their health needs and provide information for staff as to what they should be aware of, the only noticeable gap found in regard to the lack of guidance for a resident with epilepsy, although there was no evidence of them having any during their time at the home. A number of staff have however received training in respect of epilepsy. We heard from residents that spoke highly about the personal support that staff provide to them. Staff seen during the visit to the home were committed, hardworking, friendly and respectful of individual needs and choices of the residents living at New Bradley hall. We witnessed genuine and caring behaviours. Interviews with staff evidenced that they had a good knowledge base and interest in their work. The only comments we received that detract from this is due to the homes reliance at times on agency staff that do not know residents as well as the permanent staff, this however less of any issue now than it has been due to redeployment of staff from other homes to fill staff vacancies. The home does not currently have a working key worker system (i.e. staff allocated to individual residents) although the manager stated that she was close to finalising this and staff spoken to confirmed their awareness of this development. Staff spoken to also have a good awareness of diversity issues such as the gender of carers that residents preferred, this issue reflecting documented preferences in the resident’s files. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Those medication records are were fully completed, contain required entries, and were signed by appropriate staff. There are weekly management audits to monitor compliance. Those residents whose care was tracked did not manage their own medication, although this was with their consent, and ability. The home’s procedures do however allow for residents to self medicate within a risk management framework. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 12 Based on previous inspections and audits carried out by the homes contracted pharmacist (copies of visit reports seen), the home has a good record of compliance with the receipt, administration, safekeeping, and disposal of medications including controlled drugs (although only a small number of the latter are held at the home). Only seniors administer medication during daytime hours and these staff have completed and passed an appropriate medication course. It is possible based on comment from the manager that night staff may administer such as GTN sprays and paracetomol during the night, and as a result these staff have been identified as needing accredited medication training by management. We observed and were told about many ways in which staff respect and uphold residents privacy and dignity this including knocking doors, calling residents by their preferred names, ensuring they were covered up appropriately when receiving intimate care and allowing them independence where they were able. The homes policies and procedures support the ways in which staff uphold and promote privacy and dignity. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about and have some control over their life style, including assistance in developing their abilities. Social, educational, cultural and recreational activities are now better meeting individual’s expectations although there is recognition of areas where improvement is needed. The meals available to residents are meeting their expectations. . EVIDENCE: We were told prior to the visit to the home that three out of four residents responding felt that there ‘could be more stimulation’ this supported by comments from relatives who commented on the need for ‘more regular activities to help improve mental stimulation’. Comments from residents during the visit to the home did however indicated that they were no concerns as to the level of stimulation, this suggesting that since the previous comments had been made there may have been improvement. Comments from one resident was that the home does “wonderful things such as summer fetes and trips out and entertainment, which costs us very little”. Other residents stated that they were never bored and all indicated that their daily New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 14 routines were flexible and in keeping with their preferences (as was seen to be documented in individual files). Residents where able can walk in the extensive grounds of the home or to the local village of Kingswinford. The manager told us (in the AQAA) that the home could do better by arranging more flexible transport to improve community access and needed to continue to improve daily life and social activities, this to be assisted by the purchase of additional activity equipment. There was evidence from meetings with residents that they are consulted as to their prefrences as a group and following up on the agreements in the meeting minutes we did find that some of these had been actioned. These minutes were seen to be available on notice boards around the home with copies of activity programmes on the same boards. Records of activities carried out are kept on each unit although staff need to ensure these are always completed. Where residents told us they wished to pusue their chosen religion we were told in one instance ‘ that they were able to go to church when they wished’ and a service was seen to take place at the home on the first day of the visit to the home. It was pleasing to see that two of the residents whose care was explored have developed their abilities in respect of such as self care based on assessments at the time of admissions and their current abilities (as seen and stated by the individuals themselves). The home has a clear visitors policy that is flexible and the majority of relatives responding to questionnaires stated that the home was usually good at keeping them up to date with important issues. There was only one comment from a relative stating that they had not been informed as to a resident’s fall, this lack of communication not reflected in other comments received. We saw that home has completed nutritional assessments for residents and there have been developments with use of a new monitoring tool based on monitoring residents weights, with information fed back to senior management where any concerns, if any, would be highlighted. We were told that the food provided by the home was good and that residents have a choice as what they wish to eat. We saw that gentle assistance and encouragement with feeding was offered or provided and the option of a freshly brewed cup of tea or coffee was also available at meal times. Meals were served as soon as they were dished up and when we sampled these they were found to be not to hot but certainly warm enough and the meat moist, tender and extremely tasty. The vegetables were also tender and the gravy was suitable. The home has a five week menu that is displayed around the home (we saw residents using it) and changes from residents meetings are reflected within it, i.e bacon is now available most mornings as requested by residents. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure. Robust systems are in place to ensure that residents are protected from abuse although limitations could be more clearly defined. EVIDENCE: The service was seen to have a complaints procedure that is clearly written and easy to understand and is available in larger print. The complaints procedure is available to everyone living at the home within the service users guide (seen to be available in bedrooms) and on a number of notice boards by residents living areas. Residents and relatives we spoke to stated that they usually knew who to speak to when wishing to make a complaint. The home was seen to have a record of complaints made that included details of the investigation and any actions taken, including informing the complainant as to what was happening. In exceptional circumstances, and if the service does not respond in agreed timescales the complainant would be made aware of this. There was nothing to indicate that there have been any complaints made about the same issue twice in the last 12 months. We saw that the policies and procedures for safeguarding adults are available to staff in the home and give clear specific guidance to those using them. Staff New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 16 spoken to are in most cases aware when incidents need external input and who to refer the incident to, although there is a need for same staff to have training in safeguarding, this identified by the manager who stated she has put these staff forward for this training. The home has a clear system for staff to report concerns about colleagues and managers that staff are aware of, with statement to the fact that felt they would be able to do so if the situation demanded it. There have been recent incidents that have demonstrated that the management understand the procedures for safeguarding adults, with attendance at meetings and the provision of information to external agencies as needed. Incidents dealt with through the safeguarding adults procedures have been seen to be well managed and appropriate actions have been taken to protect the residents. There was little evidence of the home limiting residents, this based on their comments although there was one resident seen to have difficultly leaving their room independently due to the fire door and the fact that they used a wheelchair. The provision of an automatic door opener could allow this resident independence when leaving or entering their room. Individual assessments in respect of peoples capacity for involvement in the decision making process about any limitations to their lifestyle would be recommended to clarify capacity, and any potential limitations that may result from this, these then potentially needing discussion in a multi- disciplinary forum New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 17 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): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which for most residents encourages independence. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of most of the people who live there. The well-maintained environment provides a range of specialist aids and equipment to meet residents assessed needs including shaft lifts, adapted baths, pressure pads linked to the call system etc. There were however no automatic door openers for independent wheelchair users. The home is a very pleasant, and based on the homes maintenance a safe place to live. Bedrooms are of sufficient or in cases larger New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 18 than expected sizes and all are fitted with a generous ensuite that includes a shower facility. The home has been proactive in having had an environmental audit carried out by sensory specialists, and has partly responded to the recommendations from their report. There are issues with the exterior drive to the home with limited space for parking and work needed to ensure that there is a safe and level surface. The lay out and design of the home allows for smaller groups of people to live together in a pleasant, spacious and airy environment, with ample rooms available for residents to have privacy. It was noted that some bedrooms were quite dim until the point where the energy saving bulbs warmed up, these the rooms to the back of the home that were screened by trees more so than at the front. We saw that residents are able to personalise their bedrooms and make these areas individual and the range of furniture available meets the needs of individuals although can be changed if their needs change. We were told that keys to rooms are available if residents wish to hold them. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. The home was said by residents to be warm (as was the case on the days of the visits) and water available is warm but not to hot. All radiators and hot pipes are suitably protected. The home is clean and tidy and smells fresh having just a “clean” smell. There were the usual smells of clean washing around the laundry area, lingering toast aromas in the upper and lower kitchenette areas but it was really pleasing to not be overpowered by a heavy scents usually associated with air fresheners. Residents also told us that the home is clean and fresh as we saw when visiting, as it was spotlessly clean throughout. Staff in discussion were well aware of how to promote good infection control and a number spoken to had received training in the same. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 19 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 This judgement has been made using available evidence including a visit to this service. The excessive use of agency staff to maintain minimum staffing levels has at times compromised the quality of the individual care and support that residents receive although there are now more well trained and skilled permanent staff available which has improved the consistency of the service. EVIDENCE: We received mixed comments in respect of the homes staffing arrangements. On one hand we heard many positive comments as to the staff team, such as “the care staff in general show respect and kindness in their care”, “The carers are always very helpful”, “the staff very kind and friendly towards myself and helpful towards my (relative)” and “The majority of staff appear to be caring people”. We witnessed genuine and caring behaviours from the staff towards the residents and all the residents we spoke to thought highly of the staff that cared for them. On the other hand there was comment from relatives (via questionnaires) that some staff were not ‘personable’, Improvement could be reached “by making sure that the younger carers know what they are doing” and that some agency staff (although comment was made that some were very caring) don’t “seem to want to do anything for their money except just turn up – I was there one day when regular staff had to ask two of them if they would give her help – another occasion I found one lying on a settee New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 20 reading a paper out of the way of being seen”. There was also comment from some of the staff spoken to that some of the agency staff ‘were carried’ when they had no or little experience of the home and were part of the minimum staff complement. We discussed the use of agency staff with the manager in part due to comments such as those detailed above and the pre inspection information from the home indicating that there were times where over half the care hours were made up with agency staff. This situation was stated to have arisen as a result of keeping staff vacancies open for redeployment of staff from another home the provider was closing. As a result of this 8 staff vacancies have been filled, this improving the situation, which would explain the disparity between comments received pre inspection and during our time at the home. There is still however a reliance on the use of agency staff with the home still having some vacancies and some difficulties on the first day of the visit when both agency and employed care staff had called in sick. The manager was aware and mindful of the excessive use of agency staff in the recent past and was trying to ensure that there was no more than two used per shift although situations where staff ring in sick do create situations that can be difficult to deal with in the short term. The manager stated that they are using agency staff to cover one night vacancy but are trying to cut down on the use of agency at night. To counter the difficulties with use of agency staff every attempt is made to use those staff that have worked at the home previously. The manager was clear as to the importance she attached to training and spoke of trying to deliver a programme that meets any statutory requirements and national guidance. Based on comments from staff and sight of certificates from a sample of staff files evidence suggests that staff are well trained, and where there are gaps the manager is aware of these and is trying to obtain this training from the providers central training department. It was stated that there are sometimes difficulties getting staff on training courses due to oversubscription however. Discussion with staff showed that they had a good awareness of care related issues, are clear regarding their role and what is expected of them and it was pleasing to see that there are well over 50 of permanent staff with a vocational qualification (NVQ 2) in care. The manager also spoke of a range of training that she felt would be beneficial for staff including nutrition, hydration and dementia care. The service has a robust recruitment procedure that is followed in practice and meets expected statutory requirements and National Minimum Standards with accurate recording at all stages of the process. The manager also evidenced that checks are carried out to ensure that agency staff meet minimum standards (for example been subject to enhanced disclosures and references). There was evidence to support the manager’s statement that staff are inducted to the home through use of a national recognised tool. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 21 There is based on sight of some staff files, comments from staff and confirmation by the manager a lack of regular supervision for staff. The manager stated she was aware of this and was looking to improve in this area. Despite this staff were positive about the support they receive from management even though it was on an ad hoc basis. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management and administration of the home is overall effective in ensuring that good outcomes for residents are delivered. Staff do not always have time to reflect on good practice and individual support for them is lacking this having the potential to compromise the homes success, despite effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The Registered Manager, who has managed New Bradley Hall for some years, holds the expected management qualifications and has experience from numerous years of management of care homes. The manager showed a good understanding of the working of the provider organisation in respect of such as New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 23 the planning and business systems. There were however issues that came to light following discussion with the senior team that identified that there were some concerns in respect of morale, this partly stemming from seniors having little time to spend working together so as to share information and concentrate on such as team building. Discussion with the manager indicated that she was aware of issues in terms of staff morale and was looking to address these by giving seniors time to jointly reflect on their practice. The lack of supervision is to be seen as a potential factor here as is the fact that the manager has had a recent period of sick leave. The pre inspection information submitted by the manager contained clear and relevant information that was found to be accurate. This information clearly informed us about changes in the service and where further improvement was needed. There are several mechanisms for quality assurance within the home. The home has introduced an checklist that uses the National Minimum Standards as a base, this to be completed over a 12 month period (in progress at present) with the senior staff carrying out audits against these standards. Feedback forms for stakeholders and residents are available and these are completed with residents by staff from other of the provider’s homes to ensure objectivity. Results are then collated by senior management who let the home have the summarised results. These satisfaction surveys cover areas such as personal care, environment, food, staff attitude, activities, laundry, maintenance and dealing with complaints. It was stated that a questionnaire for relatives is still in the developmental stages. The manager also attends meetings with other managers in the borough and discusses practice and management issues. The last report received by the Commission for Social Care Inspection in respect of visits to the home by representatives of the provider was in March 2007. This was discussed with the manager who confirmed that there have only been three visits over the last 12 months indicating limited monitoring of the home (in terms of physical presence). These visits and reports must be on a monthly basis, this necessary to ensure senior management maintain a visible presence for residents and staff. The perception of some staff was that senior management only visit when there is a problem. A range of strong policies and procedures supports the home, these also including clear reference to management of diversity issues. There were inconsistencies noted in some of the record keeping in care records that need to be better managed, for example personal care checklist inconsistently completed, ensuring all the information in assessments is fully capitalised on in care plans and the latter are accurate and consistently up to date and that entries in respect of all visits from medical professionals are maintained in case files as opposed to other records. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 24 Finances are managed by the resident, their relative, or through an appointee. Small amounts are held by the home for safekeeping. 2 staff members sign any withdrawals or deposits and a receipt is kept. Audits are undertaken periodically to ensure accuracy is maintained. There was clear evidence that residents property outside of safekeeping is logged on inventory forms, these when sampled found to be accurate. 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. Staff spoken to also showed a good understanding of what safe working practices involved and what actions they should take to ensure that residents are safe. New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 25 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 3 3 X 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 4 2 3 4 3 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 1 2 3 New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP27 Regulation 18(1) b Requirement The registered persons must ensure that the use of agency staff does not in any way compromise the quality of the individual care and support to residents. All care (and senor staff) must be supervised at least six times per annum. This is an outstanding requirement from 19th October 2004. There has been some inconsistent improvement in this area. Staff at the home are still not been individually supported and there are concerns that this will impact upon morale and ultimately effective management of the home. The Registered Provider must ensure that the responsible Individual or other representatives carry out monthly visits to the home to support the manager and monitor its performance with copies of subsequent reports DS0000039054.V348610.R01.S.doc Timescale for action 31/05/08 2. OP36 18(2) 31/05/08 3. OP32 26 31/05/08 New Bradley Hall Version 5.2 Page 27 forwarded to CSCI. 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 OP12 Good Practice Recommendations The registered manager should continue to ensure that all residents receive sufficient social activity and stimulation in keeping with their personal preferences, and that evidence of provision of this is clearly and consistently documented. The registered provider should ensure that the drive to the home is free from hazards and that consideration should be given to the provision of additional car parking space. The registered provider should consider the fitting of automatically opening doors to promote the independence of wheelchairs users. The registered manager should ensure that there is clearly identification of staff training within a training matrix that shows all training staff hold, need and are booked on to attend. The registered persons should ensure that the senior team have time to reflect on their practice as a group through use of such as management planning days. The registered manager should ensure that staff take care so that all care records are accurately and consistently completed. 2. 3. 4. OP19 OP22 OP30 5. 6. OP31 OP37 New Bradley Hall DS0000039054.V348610.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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.V348610.R01.S.doc Version 5.2 Page 29 - 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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