Inspection on 30/08/05 for The Bradbury Centre

This inspection was carried out on 30th August 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

The Bradbury Centre 31/08/06

The Bradbury Centre 29/11/05

The Bradbury Centre 24/01/05

The Bradbury Centre 21/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE The Bradbury Centre 68 Manygate Lane Shepperton Middlesex TW17 9EE Lead Inspector Mr P Benthom Unannounced Inspection 30 August 2005 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 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. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Bradbury Centre Address 68 Manygate Lane Shepperton Middlesex TW17 9EE 01932 226698 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Royal Surgical Aid Society - Age Care Mrs Lorna Brown CRH (N) 50 Category(ies) of Dementia - over 65 years of age (DE(E)) 26. registration, with number of places Old age, not falling within any other category (OP) 24. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users within the category OP or DE may be admitted from the age of 60 YEARS. 2. In addittion to the primary condition of Dementia or Old Age up to 30 service users may have a secondary condition of physical disability PD(E) or PD. 3. In addittion to the primary condition of Dementia or Old Age up to 6 Service Users may have a secondary condition of Sensory Impairment SI or SI(E). 4. One service user from the age of 57 years may be accommodated. Date of last inspection 24 January 2005 Brief Description of the Service: The Bradbury Centre is a purpose built care home with nursing for older people operated by Age Care: The Royal Surgical Aid Society. Service provision includes specialist dementia care and frail elderly care and facilities are suitable to meet the needs of service users with physical disabilities. Respite care may be available subject to vacancies. The building is single storey designed in 4 wings connected by a large concourse. Each living unit is domestic in scale and character affording all single bedroom accommodation, assisted bathing facilities, kitchenettes, dining, lounge and quiet areas. The home’s layout incorporates best design principles for dementia care and is wheelchair accessible throughout. Bedrooms each have a pleasant outlook onto the attractive enclosed well furnished grounds with suitable wide pathways, shaded areas, summerhouse, large gazebo, vegetable plot and sensory garden. A full time matron/manager and assistant manager is employed. The care team includes a dementia nurse specialist and senior nurse for the elderly frail units, registered nurses, Physio Aid, activities co-ordinator, trained care assistants, qualified catering staff and trained housekeeping support staff. The home’s location is in a residential area close to shops, churches and all community facilities. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Home’s performance was measured against the National Minimum Standards for Care Homes for Older People. A tour of the premises took place and care, training and medication records were inspected. Staff and service users were spoken with and observation of practice was made. The CSCI would like to thank staff and service users for their hospitality throughout the inspection process. What the service does well: What has improved since the last inspection? The homes admission policy and procedures ensured admissions were on the basis of a full needs assessment. Staff individually and collectively had the required level of skill and experience to deliver services and care in accordance with the home’s Statement of Purpose. Care planning involved consultation with service users and/or their representatives. Files sampled on the day of the inspection contained comprehensive care plans, which were regularly reviewed. Risk assessments were seen and proven to be accurate and up to date. The home had a range of appropriate activities available to the service users. The complaint procedure was seen as part of the inspection process. The procedure was simple and clear and accessible to the service users and their representatives. The home was safe and well maintained, meeting service users’ needs in a comfortable and homely way. Service users’ rooms were furnished to a good standard and they were encouraged to bring with them personal belongings. The home was observed to operate a recruitment procedure based upon equal opportunities and adequate checks, which promoted the protection of the service users. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 6 Appropriate records were observed to be in place, which were well maintained and accurate. Service users and as appropriate, their representatives, were stated to be informed of their right to access information held by the home in personal records. 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 Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 and 6 Service users are admitted only following a full assessment undertaken by people trained to do so. The registered person was able to demonstrate the homes capacity to meet the assessed needs. All service users have a written contract and care plan. The home is clear in the care it offers to service users. EVIDENCE: All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. Service users and their families/representatives and relevant professionals are involved in the assessment process. Staff individually and collectively had the required level of skill and experience to deliver services and care in accordance with the home’s statement of purpose. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7, 8, 9 and 10 Health, personal and social care needs are effectively met in this home. Service users’ health needs were well met and medication administration was accomplished satisfactorily. The service plans in place were comprehensive and are reviewed on a regular basis to ensure that they accurately depict service users’ needs. EVIDENCE: Encouragement and support was given to service users to promote independence within the limitation of each individual’s capabilities The manager stated that all service users were registered with the local GP practice for the provision of general medical services. A policy and procedure for the administration of medication was sampled as part of the inspection process. Medication is stored in locked metal cabinets on both units and all qualified staff are trained in the administration of medication. During the inspection the staff cared for Service Users in a respectful manner. Those Service Users requiring any assistance were helped sensitively. All Service Users have their own bedroom, thus providing the opportunity for privacy when visitors arrive, whether family or professionals. The Homes’ policies and procedures placed particular emphasis on the core values of caring, such as independence, privacy and dignity. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13, 14 and 15 Links with the local community are good and serve to enrich Service Users lives. Activity programmes were in place, and service users were able to maintain contact with friends and family. EVIDENCE: There is a full time activities organiser in post and the sessions take place in the central concourse. On the day of the inspection several Service Users were enjoying a reminiscence quiz. The staff were seen to be encouraging Service users to make full advantage of the daily activity programme that is made available to Service Users. Links with the local community are good and serve to enrich Service Users lives. Activity programmes were in place, and service users were able to maintain contact with friends and family. There are no restrictions in terms of visiting times. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 11 The service users were free to move around the home consistent with individual risk assessments in place. The menus viewed showed a good variety of meals offered. The chef has worked in the home for a number of years and is well versed in special dietary requirements. Specially pureed diets are available for Service Users with swallowing difficulties. These are attractively presented to resemble the item that has been pureed. For example chicken is moulded to look like a chicken fillet, to very positive effect. Each unit has an attractive dining area and meals are served from the food trolley to service users in each area. Each unit has a domestic assistant who can cook hot breakfasts for service users, collects the trolleys from the kitchen at meal times and provides refreshments to service users and visitors. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16, 17 and 18 The home has a satisfactory complaints system that is made available to all Service Users and staff. Arrangements were in place in respect of adult protection matters EVIDENCE: The home’s complaint procedure is provided to service users in their welcome pack. The home complaints system is made available to all Service Users and staff. Arrangements were in place in respect of adult protection matters. There have been no complaints made in relation to the service since the last inspection. The home has an Adult Protection and a Whistle Blowing policy and procedure to safeguard service users. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and well maintained, meeting service users’ individual and collective needs in a comfortable and homely way. All areas were found to be clean, tidy and well organised. The garden was observed to be well maintained and easily accessible. The home had spacious communal sitting and dining areas. All areas met the required standard and were tastefully decorated and furnished. Specialist bathing facilities and additional toilets were provided suitable to meet the needs of the service users and in close proximity to communal areas and bedrooms. All rooms were clean and adequately ventilated. There were arrangements in place to control the temperature of the water to prevent legionella and scalding of service users. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 14 Standards of cleanliness in the kitchen in particular, were seen to be very high. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The staff had a good understanding of Service Users need. This was evident from the positive relationships that have been formed between staff and Service Users. Staff are aware of all aspects of protection of vulnerable people and appropriate up to date training is in place. EVIDENCE: The morning shift consists of at least 2 RGNs (One for each section) and 5 to 6 care staff, bringing the total of staff on duty to a minimum of 12. The afternoon shift consists of 2 RNs and 8 care staff and night staff consists of 2 RGNs and 6 care staff. The home has a large ancillary staff team consisting of a receptionist, deputy manager/bursar, maintenance man, laundry staff, kitchen staff, domestic staff and a gardener. They also have a group of volunteers making up the Friends of Bradbury Centre. Over 70 of Care staff have achieved NVQ level 2. There was evidence that a thorough recruitment process had been followed and met the standards for protection of Service Users. There are arrangements to carry out CRB checks and two written references plus an occupational health assessment is in place for all staff. Excellent training opportunities are in place for all staff. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35, 36, 37 and 38 The manager is supported by the proprietors and staff in providing clear and consistent leadership in the home with staff on duty demonstrating an awareness of their roles and responsibilities EVIDENCE: Information from service users and staff confirmed that the management style in the home was open and that registered the providers are approachable at all times. Meetings were held for both staff and service users; all were encouraged to contribute to the development of the home. Records required for the protection of service users and sampled on the day of the inspection were well maintained, accurate, and up to date. The staff-training programme includes training in first aid, manual handling, infection control, fire safety, health and safety and basic food hygiene. Systems were in place to safeguard the health and safety and welfare of the service users. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 17 The accounting and financial procedures in the home were seen to be of an good and well maintained standard. The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 19 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement There are to be no requirements from this inspection Timescale for action 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 Good Practice Recommendations There are to be no recommendations from this inspection The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. Extracts may not be used or reproduced without the express permission of CSCI The Bradbury Centre H58-H09 s17595 The Bradbury Centre v221945 300805 Stage 4.doc Version 1.40 Page 21 - 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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