CARE HOME ADULTS 18-65
Bridge House Bayer Street Coseley West Midlands WV14 9DS Lead Inspector
Mrs Jean Edwards Unannounced Inspection 17th November 2005 09:00 Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 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 Bridge House DS0000041949.V264281.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bridge House Address Bayer Street Coseley West Midlands WV14 9DS 01384 813450 01384 813451 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 Mrs Jannett Telfer Care Home 14 Category(ies) of Physical disability (14) registration, with number of places Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All requirements contained within the registration report of 11 & 12 December 2002 are met within the timescales contained within the action plan agreed between Dudley Metropolitan Borough Council and the National Care Standards Commission. Service users in the category PD(E) may be accommodated at the home for as long as the home is able to demonstrate that their needs can be met. 04/05/05 2. Date of last inspection Brief Description of the Service: Bridge House is a purpose built Residential Care Home for up to fourteen younger adults with physical disabilities, owned and supported by Dudley Metropolitan Borough Council. The Organisation intends to provide 8 permanent placements and 6 short stay respite beds. The property is located near to Roseville village, Coseley. There are many local amenities nearby and the Home is within walking distance of several good bus services to nearby towns. The Home has ample car-parking facilities; to the rear there are gardens, with shrubs and trees. The majority of the interior of the Home provides corridors, which are spacious and have ease of access for wheelchair users. The Home provides 14 single bedrooms; including one, which has ensuite facilities. There is one bathroom, one shower and five toilets for communal use. Communal areas include a dining room, three seating areas around the Home, one of which is a quiet patio lounge, which doubles as a library. There is a stable staff team of twenty-five people, including the Registered Manager, currently supplemented by agency staff. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection has taken place over one weekday. The purpose of this inspection visit is to assess progress towards meeting the national minimum standards and the homes progress to improve areas identified at previous inspection visits. A range of inspection methods has been used to make judgements and obtain evidence, which include: discussions with the Registered Manager, the senior care officer, residents and other staff. A number of records and documents have been examined. Other information was gathered prior to the inspection visit, from the report of a visit undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. Seven residents are in residence at the time of this visit and four people have chosen to stay at Bridge House during the day of the visit. Two residents in particular have been eager to be involved in the inspection process and the majority of other residents have been involved in discussions in varying degrees. What the service does well:
The registered manager has responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place. The registered manager continues to demonstrate commitment to making sure that improvements happen, where she has the authority to make decisions. The residents are encouraged to treat Bridge House as their own home and to be as independent as they are able to be. Residents make their own choices and are active in running their own residents meetings; staff can only attend if they are invited. There are wide ranges of topics discussed, with views freely aired about the running of the home, such as mealtimes and arrangements for the Christmas party on 13 December 2005, and other entertainments. Residents are enthusiastic about arrangements to go to a local pub, the Hungry Horse, on 30 November 2005. All residents at Bridge House independently manage their own financial affairs and have their own baking arrangements, without any intrusion from the home. People can choose to attend daytime activities provided by the local authority or pursue their own leisure time activities in the community or at Bridge House. One person continues to do voluntary work at a local day centre for older people and another person attends college for a computer course. Residents say they are very well supported by staff with whatever they want to do. Wherever possible residents are encouraged and supported to maintain regular contact with family and friends.
Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 6 Bridge House is well adapted to suit the needs of the residents, providing them with easy wheelchair access to all areas. The home is clean, tidy, homely and comfortable, providing residents with a pleasant place in which to live. Bridge House has a stable staff group; many people have worked at the home for a long time and know the residents well. They are caring, committed and flexible, often willing to work extra shifts, especially to support residents with outings in trips away from the home. Residents spoken to described the staff as ‘friendly’, ‘helpful and ‘good fun’. The staff are cheerful and keen to share their views and answered questions in an open and honest manner. During discussions staff have shown a dedicated approach to their work; they clearly know residents’ likes and dislikes and how to meet their needs. There has been lots of friendly banter between staff and residents during the visit. This inspection has been conducted with full co-operation of the registered manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The manager has made sure that there are detailed plans in place for people visiting Bridge House for short respite stays. There is now a photograph on file of people visiting for short respite stays. These plans give staff guidance as to how to meet each persons care needs. Each person has been asked to date and sign their care plan to show that they are in agreement and the plans are reviewed at regular intervals. The staff have made some improvements to the residents daily notes by writing fuller details of the care offered, though further expansion is required to reflect the details of the care plan. One of the older residents is at increased risks of falling and the home has assessed the risks and introduced practical measures to minimise the risks. The control measures need to be recorded so that all staff have good awareness. The records of healthcare checks, such as the annual health check, dental, optical, auditory, chiropody appointments have been improved and are now very detailed. The records show whether each person has attended well person appointments and screening for breast, cervical or testicular cancer, with any refusals noted. The home has made excellent progress with obtaining medication reviews for all residents with their GP. There are good records in place to show the results of the discussions about each persons medicines. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 7 The manager has taken action to find out about concerns raised by one resident at the previous inspection visit. The person had been upset by someones comments. The manager acted swiftly to investigate and resolve the matter to the residents satisfaction. Staff personnel files have been improved and all staff files now contain a recent photograph of the member of staff. This improves the level of safeguards in place for residents. The registered manager and the staff team are committed to be involved in further training and personal development in order to provide an improved service for the people living at Bridge house. A senior member of staff has been designated to take responsibility for making sure that the training needs of staff are identified, that each person has a training and development plan and that there is an overall training plan for the home. Records at the home have generally improved in a number of areas, for example there are records on file to show that all residents have regular multidisciplinary reviews and these are now signed by the resident or their representative. The manager and staff have made improvements to health and safety processes at the Bridge House. Examples are that the homes fire risk assessment has been reviewed and updated, which provides good safeguards to residents and staff regarding fire safety; and action has been taken to rectify potential risks posed by deficits identified on the hoists service dated 2/2/05, making sure lifting equipment is safe. What they could do better:
The organisation is in the process of introducing new paperwork for residents care plans. The new care plans must include all relevant information transferred from the existing care plans, for example each persons preferred daily routines and details of their what medicines they need and how they are to be given. As with any change residents and staff expressed some reservations about the new care plans. When the process of developing the new care plans is complete, plans must be agreed and appropriately signed by the resident and / or their representative. Although the homes system for managing residents medication is generally satisfactory, a small number of improvements must be made. Examples are to make sure that handwritten medication records are signed and witnessed by two staff. Staffing levels at the home continue to be maintained to provide adequate numbers of staff to provide a satisfactory service. However this is continues to be achieved with existing staff working longer than their contracted hours, the use of supplementary agency staff and members of senior staff from another
Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 8 home. This has the potential for care to be inconsistent for residents’ and some of their needs and preferences may not be met. The organisation must come to an agreement with the Commission for Social Care Inspection for a consistent staff team, which has the capacity to meet the needs of people permanently living at Bridge House and any people visiting for a short stay. Accelerated progress must be continued for all staff to receive the training required to meet the needs of the residents. The organisation still needs to improve policies, procedures and staff awareness particularly relating to the protection of vulnerable people from abuse, offering more safeguards to protect the residents living at this home. Some aspects of the premises do not entirely meet the needs of residents. For example, the fire exit from the residents’ kitchen is not independently accessible for people in wheelchairs. The organisation must make sure that the external environment is made safe for people who are wheelchair users and provide financial resources to redecorate the remainder of the interior of the home to a satisfactory standard. These are long outstanding requirements. 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. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Limited progress has been made to update contracts/terms and conditions of occupancy, especially relating to residents accommodated for respite stays. This has the effect that residents and their advocates do not have sufficient information regarding their rights and entitlements and any agreed restrictions. EVIDENCE: The majority of these standards have been assessed at the inspection visit on 4 May 2005 and were generally satisfactory. The home has had no new admissions since the last inspection visit. Assessment of a sample of residents case files indicates that there has been no change to the existing contract / terms and conditions of residence, though staff state that the existing document is being revised by the organisation. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 There is a new care planning system being implemented, as yet it is unclear whether it will be adequate to provide staff with the information they need to satisfactorily and consistently meet service users needs. There is some improvement in providing more detailed daily records. EVIDENCE: From the sample of residents case files assessed and from discussions there is evidence that the previous requirement to ensure that there are comprehensive care plans in place for people visiting for short respite stays. There are now photographs on each short stay residents case file. The care plans for temporary residents are detailed and now identify all assessed needs and are now signed, dated and reviewed at appropriate intervals. There is evidence that all residents have a care plan in place. The staff are in the process of transferring recorded information from existing care plans. However though the new care plan formats have advantages such as checklist and background information, there are significant omissions such as preferred daily routines and medication regimes. Two completed new care format have
Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 12 not yet been agreed or appropriately signed by the resident and / or their representative. The residents daily notes assessed now contain fuller details of the care offered, however further expansion is required to reflect how goals and care needs identified in the care plan are evaluated. One of the older residents has been identified as being at risk of falling and though a documented falls risk assessment has been undertaken, it is incomplete and does not currently identify what control measures are in place. From discussions there are practical measures to minimise this persons risk of falls. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Links with families, friends and the local community are good, enriching residents opportunities for social stimulation. EVIDENCE: The majority of these standards have been assessed at the inspection visit on 4 May 2005 and are generally satisfactory. There is a visiting policy, which is displayed in the home. Visitors can be received in private in residents’ bedrooms and in the library (though this area is used as a designated smoking area) or in the patio lounge. Discussions with the residents and examination of a sample of records indicate that every effort is made to promote positive relationships with family members, friendships in the wider community and within the home. Each person has a varying amount of contact with family and friends, with details of additional support from staff at the home recorded in case files. Residents are able to develop personal and intimate relationships if they wish. People are encouraged to seek specialist advice and support in these circumstances. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,21 The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. EVIDENCE: There are improved records of healthcare checks, which are now more detailed. On the sample of case files examined there is written evidence of annual health checks, dental, optical, auditory, chiropody, and well person screening for breast, cervical or testicular cancer as appropriate with refusals noted. For example one person had her breast screening results, which are negative, on her file. Another person had been offered an appointment for cervical screening, which she had declined to attend, though it is noted she will continue to be offered future appointments. The manager has been very proactive seeking medication reviews for all residents with their GP. Written correspondence is available on files requesting medication reviews. The GP has sent the results for all residents reviews to the home, however this is a generic letter referring to all residents reviewed, which does not comply with Data Protection legislation. The letter is held on
Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 15 the medication system and the home has taken action to preserve residents privacy, entering individual details on each persons case file. A brief observation of the homes medication system, established the previous minor deficits have been rectified. However a small number of additional improvements are needed. Examples are that two handwritten MAR sheets do not contain the same level of detail as pre-printed sheets, such as dose, form, route, time and they have not been signed and witnessed by two staff. The MAR sheets do not always show carried forward medication stocks. This makes auditing and tracking medication stocks more difficult. There have been minor errors, which have been dealt with appropriately, however staff are not aware of the need to notify the CSCI office of any medication errors. No mention of the required notification appears in the copy of the medication policy available at the home. Generally medication is well managed by senior staff, with accredited training and a good working knowledge of residents medication needs. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Policies, procedures, guidance and staff training need to be fully implemented in order to provide residents with satisfactory safeguards from abuse. EVIDENCE: There have been no complaints recorded in the home’s complaints log since the last inspection visit in May 2005. The residents say they feel that they can raise any general concerns through their meetings or individually with the manager or staff at the home. One person involved in an altercation with another residents has not registered a formal complaint, however there is satisfactory evidence of appropriate support, investigation and resolution. The Registered Manager has explored and resolved an issue of concern raised by one resident at the previous visit in May 2005. Detailed information including the outcome has been formally notified to the CSCI Office, Halesowen. The manager and staff are aware of the multidisciplinary procedure Safeguard and Protect for the protection of vulnerable adults; and there is a copy readily available in the office. The home does not currently have documentary evidence that all staff have read the policy guidance. It is strongly recommended that staff signatures are obtained to demonstrate awareness and understanding of their responsibilities. Limited progress is now being made to ensure all staff are provided with appropriate levels of training so that they are aware of and are able to respond appropriately situations, which require them to take action to protect vulnerable people.
Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The home presents as a homely and comfortable environment for residents. The manager has a good understanding of the areas where the home needs to improve and proactive planning is now in place for this improvement to be resourced and managed. EVIDENCE: The majority of these standards have been assessed at the inspection visit on 4 May 2005 and were generally satisfactory. Where previous requirements are not fully met, revised timescales have been issued. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36 No further progress has been made in addressing substantive staffing levels and though residents generally receive consistent care, there is a risk that this may not always be maintained. EVIDENCE: There is a stable core group of long serving staff and there have been no resignations since the last inspection visit in May 2005. One member of night staff is due to retire and the manager plans to split the full time post into two part time posts to achieve greater flexibility, especially with night time cover. There is also one vacant post for a relief care assistant. The home is continuing to manage to meet the minimum staffing requirements issued at the previous inspection visits with the use of staff working in excess of contractual hours, agency staff and by ‘borrowing’ staff, particularly seniors from other homes within the organisation. Although this provides reasonable consistency of care for residents, there is a reliance on the availability and goodwill of exiting and temporary staff. The requirement for the organisation to provide revised staffing proposals to the CSCI to demonstrate that there will be sufficient numbers of staff to meet the needs of the people permanently living at Bridge House and any people who may be at the home for respite or short stays, remains long outstanding. Action must be taken as a priority to address this requirement. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 19 Staff files have not been examined at this visit, however there is satisfactory evidence that the home has met the previous requirement to provide a recent photograph of the member of staff most recently recruited, which is now on the personnel file. There is warm and empathetic rapport between the residents and staff. Residents are looking forward to events with the staff to celebrate Christmas and they teased and laughed with various members of staff about their singing abilities. People are complimentary about the staff, their helpfulness and thoughtfulness. Residents comment that they are appreciative of staff giving them time, though they feel staff are still very busy at times during the day. Good progress is continuing to meet previous requirements relating to staff training. A senior care officer takes responsibility for organising and sourcing different types of training, for staff to meet the needs of the residents living at Bridge house. There is a structured supervision system, with appropriate topics to support and develop each member of care staff. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40,41,42 The management of the home provides clear leadership and communication systems are generally very effective and staff are clear about their roles and responsibilities. The standard of records at this home continues to improve, which provides residents with better safeguards. EVIDENCE: The home has access to corporate and departmental policies and procedures, which are readily available for staff guidance. The organisation is in the process of reviewing various policies and procedures, though there are some which need to be updated. Examples are the policies relating to complaints and dying and death. Staff are making efforts to improve the standard of record keeping. However further improvements are needed to complete care plans and ensure all medication records are complete and signed. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 21 A sample of fire safety and maintenance service records have been examined, these are generally satisfactory, with evidence f improvements. For example the homes fire risk assessment has been reviewed and updated and there is documentation to show that the deficits identified on the hoists service dated 2/2/05 have been rectified. Accident records show that there have been 12 recorded accidents involving residents and 3 recorded accidents involving staff since the visit in May 2005, however there is no evidence available at this visit that a regular accident analysis has taken place. Furthermore no progress has been made to provide the manager and senior staff with training to effectively promote the management of risks and health and safety. Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 2 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bridge House Score X X 2 2 Standard No 37 38 39 40 41 42 43 Score X X X 2 2 2 X DS0000041949.V264281.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1)(b) 15(1) Timescale for action To ensure that any restrictions of 01/02/06 choice or personal freedoms are recorded as part of the contract /terms and conditions, as well as the individual plan (Timescale of 31/01/05 and 30/06/05 Not Fully Met) To ensure that agreed limitations 01/02/06 on choice, freedom or decisionmaking are clearly documented as part of the service user plan, examples: going out, bathing, smoking un-chaperoned (Timescale of 31/01/05 and 30/06/05 Not Fully Met) The residents daily notes must 01/02/06 be expanded to reflect fuller details of the care offered, as identified in the care plan (Timescale of 30/06/05 Not Fully Met) The new care plans must include 01/02/06 all relevant information transferred from the existing care plans, for example daily routines and medication regimes To ensure that the new care 01/02/06 format is agreed and appropriately signed by the resident and / or their
DS0000041949.V264281.R01.S.doc Version 5.0 Page 24 Requirement 2. YA6 15(1) 17(1)(2) 3. YA6 15(1) 17(1)(2) 4. YA6 15(1) 17(1)(2) 5. YA6 15(1) 17(1)(2) Bridge House representative 6. YA9 13(4) A documented falls risk assessment must be undertaken and regularly reviewed for the resident discussed during the visit (N) and for any other person identified to be at risk of falls (Timescale of 30/06/05 Not Fully Met) 1) To ensure that handwritten MAR sheets contain the same level of detail as pre-printed sheets, such as dose, form, route, time 2) To ensure handwritten entries or changes on MAR sheets are signed and witnessed by two staff 3) To record carried forward medication stocks on MAR sheets 4) To expand the medication policy to ensure that all medication errors and corrective actions are notified to the CSCI office, Halesowen, as a Regulation 37 matter To ensure that the Organisation 01/02/06 reviews and updates the policy, procedure and useful flowchart, dating from 1994. (Timescale of 31/01/05 and 31/07/05 Not Fully Met) To update the corporate 01/02/06 complaints procedure to include a 28 day timescale of response and details of the CSCI. (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 1) To progress training for all 01/02/06 staff relating to the areas of responding to allegations of suspected abuse and protection of vulnerable adults, dealing with aggression/challenging behaviour, and use of physical or
DS0000041949.V264281.R01.S.doc Version 5.0 Page 25 01/02/06 7. YA20 13(2) 01/12/06 8. YA21 17 (1) 9. YA22 22 10. YA23 13(6) Bridge House non-physical intervention (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 2) To devise and implement step-by-step procedures relating to dealing with allegations of abuse, use of restraint etc., for staff guidance (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 11. YA23 13(6) 18(1)(c) 1) To expand the safeguard & protect policy with a simple to use flowchart, with contacts and telephone numbers for staff guidance 01/02/06 12. YA24 23(2)(b) 2) To obtain staff signatures to provide evidence that all staff have read and have an awareness of policies to protect vulnerable adults 1) To renovate / replace the floor 01/02/06 covering in the Residents kitchen, lounge, dining room, corridor areas and bedrooms identified in the maintenance programme (Timescale of 31/01/05 and 31/07/05 Not Met) 2) To continue the ongoing renovation of all doors, doorways and communal areas, which have damage caused by wheelchairs or other equipment; and seek advice for more robust protection for these areas (original timescale completed the now needs new and continuing renovation) (Timescale of 31/07/05 Not Fully Met) 3) To repair and make safe the cracked car port roof (Timescale of 31/01/05 and 31/07/05 Not Met) Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 26 13. YA27 23(2)(b) 14. YA33 18(1)(a) 4) To undertake work required to make the exit from the residents kitchen accessible for wheelchairs (Timescale of 31/01/05 and 31/07/05 Not Met, but is on the homes maintenance programme) To renovate / replace the 01/02/06 flooring in the shower room (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 1) To provide appropriate and 01/02/06 consistent senior staff cover for duties on weekends, where the previous practice of a senior member of staff working long days (14 hours) has ceased. (Timescale of 31/01/05 and 30/06/05 Not Fully Met) 2) To provide a revised staffing proposal to ensure that there are sufficient numbers of adequately trained staff available to meet the needs of existing residents and any additional people using the service for respite / short stay visits (Timescale of 30/06/05 Not Fully Met) 15. YA35 18(1)(c) 1) To ensure that all staff have awareness training and appropriate skills to appropriately deal with specialist needs such as epilepsy, strokes etc. (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 2) To ensure that all staff receive appropriate awareness training in Equal opportunities, Racism and Disability awareness (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 3) To ensure that every member of staff has an individual training 01/02/06 Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 27 16. YA39 24 and development assessment and profile (by 2004) and produce documentary evidence that all staff receive at least five paid training / development days (pro rata) each year (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 1) To devise and forward a copy of the annual development plan relating to Bridge House to the CSCI Satellite Office - Halesowen (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 2) To progress the implementation of residents surveys, with results published, included in the Service User Guide and made available to all interested parties including the CSCI satellite office (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 01/02/06 17. YA40 17,24 18. YA42 18(1)(c) To make progress to ensure that all applicable policies and procedures relating to topics set out in Appendix 2 of the National Minimum Standards for Younger Adults are put in place and reviewed on a regular basis. (Timescale of 31/01/05 and 31/07/05 Not Fully Met) 1) To ensure all staff receive mandatory training commensurate with their roles; fire training, drills twice each year, moving and handling, hoist, first aid, food hygiene, health and safety (Timescale of 31/01/05 and 31/07/05 partly met, with good progress made) 2) To provide documentary evidence that approved risk assessment awareness training 01/02/06 01/02/06 Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 28 has been arranged for all staff to be delivered within an identified timescale. (Timescale of 31/03/05 and 31/07/05 Not Met) 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. 2. 3. 4. Refer to Standard YA5 YA22 YA23 YA24 Good Practice Recommendations That where service users have additional needs, the Manager should develop and agree a revised, written and costed contract / terms and conditions - NOT MET That staff have access to awareness / training relating to new equipment / developments relating to service user needs - NOT MET That the organisation gives serious consideration to implementing a standard form to be used for allegations and referrals relating to abuse of vulnerable adults That the overhanging hedges at the rear of the Home are trimmed to an acceptable standard and garden maintenance is generally carried to the Homes satisfaction - NOT FULLY MET That staff signatures are obtained to demonstrate their awareness of the food hazard analysis -In Progress That the Manager undertakes a regular documented analysis of accidents relating to Service Users. - PARTLY MET That the Organisation should be mindful that all records including accidents records, need to be compliant with the Data Protection Act 1998 and the Care Homes Regulations 2001, i.e. that all records containing personal / sensitive information are held securely and must be retained at the Home for 3 years from the date of the last entry - Partly Met 5. 6. 7. YA42 YA42 YA42 Bridge House DS0000041949.V264281.R01.S.doc Version 5.0 Page 29 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
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