Inspection on 31/08/06 for The Bradbury Centre

This inspection was carried out on 31st August 2006.

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

The inspector 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 29/11/05

The Bradbury Centre 30/08/05

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 Unannounced Inspection 09:10 31 August 2006 st 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 The Bradbury Centre DS0000017595.V307170.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. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Bradbury Centre Address 68 Manygate Lane Shepperton Middlesex TW17 9EE 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) 01932 226698 01932 254573 bradbury@agecare.org.uk The Royal Surgical Aid Society - Age Care Mrs Lorna Veronica Brown Care Home 53 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26), of places Physical disability (32), Physical disability over 65 years of age (32), Sensory Impairment over 65 years of age (6) The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Minimum age of Service Users within categories OP, DE, PD and SI from the age of 60 YEARS. 29th November 2005 Date of last inspection 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). The home is located in a residential area convenient for shops, churches and all community facilities. Service provision includes dementia care and frail elderly care and facilities are suitable for people with physical disabilities. Respite care may be available subject to vacancies. The building is single storey and wheelchair accessible throughout. It incorporates best design principles for dementia care and is divided into four living units connected by a large concourse. Each unit is domestic in character affording all single occupancy bedrooms, assisted bathing facilities, kitchenettes, combined dining/lounges and separate sitting areas. Since the last inspection a spacious en suite bedroom has been added providing an additional dementia care place. Two spacious en-suite bedrooms were added in 2005 in the elderly frail unit, which have modern design features and overhead tracking for hoisting. There is an attractive, enclosed, well-furnished grounds with suitable wide pathways, shaded areas, summerhouse, large gazebo, vegetable plot and sensory garden. A new patio area with ramped access is a recent development. The management team comprises of a full time registered matron/manager, assistant manager, dementia nurse specialist and senior nurse for the elderly frail units. The team includes registered nurses and care staff, a part time physiotherapist - aid, activities co-ordinator, catering and housekeeping support staff and two part-time administrators. Fee charges at the time of the inspection ranged between £840 and £890 per week for ‘elderly frail’ units and £930 and £980 for ‘dementia care’ units. Information about the home’s facilities and services can be obtained directly from the Bradbury Centre. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the home in 2006. The inspection outcomes are the cumulative assessment, knowledge and experience of service provision at this home since the last inspection in 2005. It also takes into account observations during an unannounced nine – hour inspection visit on 31st August 2006 by one regulation inspector. At this time all key national minimum standards for older people were inspected and a tour of the premises took place, which included sampling bedroom accommodation. Records, policies and procedures were also sampled and discussion took place between the inspector and the registered manager, the assistant manager and all heads of departments. The activities coordinator, some nurses, health care assistants and ancillary staff were also consulted. The inspector spoke with a number of service users and some visitors. Written comments received from two service users also informed this inspection’s outcomes. The inspector would like to thank all who contributed to the inspection process. What the service does well: The registered manager is suitably qualified, competent and experienced to manage the home and meet its stated purpose, aims and objectives. The senior management team was also suitably qualified and experienced and their roles and responsibilities were clearly defined. Service users benefited from the ethos, leadership and management approach. The staff team was stable and there was a high level of commitment to staff training and development. This ensured a skilled workforce and appropriate delivery of nursing, personal and social care. It was evident that staff had developed positive relationships with service users. Also of effort made to work in partnership with families and representatives of service users and other involved professionals. The home’s atmosphere was warm and welcoming and staff were professional, friendly and supportive in their approach towards service users and visitors. Feedback from individual service users was mostly positive regarding their care and life in general at the home. In this home some of the service users were unable to verbally communicate with the inspector due to their condition. Judgements regarding their care and welfare were based on direct observation of care practice; also on the appearance, behaviours and demeanour of these individuals’ and took into account information from records also from staff and visitors. A number of service users stated they felt safe, were happy with their care and had no complaints. The management and operation of the home demonstrated good awareness and understanding of equalities and diversity in meeting needs and promoted anti-discriminatory practices. The activities coordinator described positive The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 6 measures to communicate with individuals’ whose first language was not English and for responding to cultural and religious needs. Service users interests and hobbies were established and opportunity was available for appropriate stimulation through an extensive social and leisure activity programme. Organised activities also gave particular consideration to the needs of people with impaired memory. The activity coordinator was responsible for producing a monthly programme that was responsive to service users interests. The home has an onsite small shop and hairdressing salon and aromatherapy and manicure services were available. Various excursions were organised throughout the year enabling service users to access community resources. The home benefited from a proactive League of Friends who raised funds and assisted staff with outings and social events. The home was clean and hygienic throughout at the time of the inspection visit. The environment promoted independence and was comfortable and domestic in character. Care practices were observed to safeguard service users privacy and dignity. What has improved since the last inspection? What they could do better: Whilst it was concluded that the home was overall managed and operating to a high standard, attention was required to environmental hazards relating to excessively hot water temperatures in some bedrooms and bathrooms. It is acknowledged that hot water temperatures were regularly monitored and this problem known to management. Engineers were stated to have assessed the cause and advised the need for a number of valves regulating hot water temperature to be replaced. It was positive to note immediate action implemented on the day of the inspection visit to minimise risk pending a longer – term solution to the problem. Requirement was made for these valves to be replaced within a specified timescale and until such time as this work is carried out for the risk management strategy to be maintained and closely monitored. The home’s fire risk assessment required review. Attention was drawn to the requirement for all care plans to be reviewed at least monthly in consultation with service users where practicable or their representative as appropriate. Care plans should be signed by service users whenever capable and/or The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 7 representative (if any). It was recommended that a formal system for reviewing care plans be considered affording service users where capable and their relatives/representative opportunity to discuss their care plan at specified intervals. Whilst good practice staff recruitment procedures were in place attention was drawn to the statutory requirement for management to check that new staff are not on the national Protection Of Vulnerable Adult Scheme (POVA) list before taking up post. 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 DS0000017595.V307170.R01.S.doc Version 5.2 Page 8 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 The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3.4,5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives had access to the information necessary to enable an informed choice about the suitability of the home. Prospective service users needs were assessed prior to admission. They had contracts/statements of terms and conditions, which clearly informed them about the service they would receive and of fee charges. Observations confirmed the home’s capacity to meet the assessed needs of service users. EVIDENCE: Good quality literature about the home’s services and facilities had been produced in a statement of purpose also in welcome packs containing all statutory information as a guide for service users and visitors. A brochure and copy of the statement of purpose was given to all prospective service users or their representatives at the point of contact with the home; additionally details of fee charges, terms and conditions of residency and the home’s complaint procedure. The statement of purpose and service users guide, complaint procedure and copy of the last inspection report carried out by the Commission of Social Care Inspection (CSCI) was prominently displayed in the reception The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 10 area. Discussion took place with the manager regarding recent changes to the care homes regulations and the implications of these changes. Also the need to state in the service users guide whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. A minor amendment was necessary to the statement of purpose to reflect the recent increase in bed numbers. A comprehensive needs assessment was carried out for all service users prior to admission. The manager with either the dementia nurse specialist in charge of the dementia units or head of care, who is the senior nurse responsible for the elderly frail units, undertook this assessment. This incorporated discussion with prospective service users and their family/representative and consultation with relevant professionals. Time and effort was also spent on establishing lifestyle information as well as identifying health, personal and social care needs. This practice enabled an individualised approach to care planning taking account of any cultural, religious and social preferences and to try and meet individual aspirations and expectations. For individuals referred through care management arrangements, a summary of the care management (health and social care) assessment was obtained and copy of the care plan produced for care management purposes. Service users and their representatives were welcome to view the home prior to admission and all admissions on the basis of a trial period. The home’s admission procedures included comprehensive assessments of needs and risks and care plans were generated to address these. Key workers were allocated to service users and responsible for producing and reviewing care plans. Staff were qualified and skilled to meet the needs including specialist needs of service users accommodated at the time of the inspection visit. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health and personal care that service users received was in accordance with individual needs. The principles of respect, dignity and privacy were being put into practice at the time of the inspection visit. Medication policies, procedures and practices were compliant with statutory requirements. Attention was necessary however to monitoring systems for cold storage of medication in a clinical room. EVIDENCE: Care plans and risk assessments were sampled as part of the inspection process. These were detailed documents generated from comprehensive assessments. Observations identified omission to carry out monthly reviews and to update a care plan for a service user accommodated in the frail elderly unit. The care plans sampled in the dementia unit had been reviewed monthly. The records of two service users accommodated in the elderly frail units did not evidence their involvement/consultation as part of the care planning process. It was noted that a record template was available as part of the home’s documentation to evidence involvement of service users and/or their The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 12 representatives in this process but had not been completed for these individuals. This record had been prepared for the signature of relatives of a service user accommodated in a dementia care unit following recent discussions with them and agreement about this individual’s care plan and medication regime. Observations identified the need to update the care plan of a service user accommodated on the elderly frail unit to reflect new information not available at the time of admission. Also omission to evaluate care plans for this individual at least monthly. It was also noted in the same unit that a recent accident/incident involving the same service user had not been recorded on an accident record. Areas of discussion with the manager and dementia care nurse specialist included two recent meetings with the families of service users to discuss and agree their care plans. Both meetings appeared effectively managed with positive, constructive outcomes. It was clearly demonstrated that effort was made to work in partnership and listen to relatives wherever appropriate and practicable and consult relevant professionals. It was recommended that a formal system of review meetings be considered for all service users affording regular opportunity for service users where capable and/or their representatives to engage in review processes. It is acknowledged that the inspector was informed of informal arrangements taking place. It was concluded that overall service users received a good standard of care based on available information and direct observation of care practice. Staff on duty at the time of the inspection visit demonstrated a skilled approach to communication in all units and in particular in their interaction with people with dementia and short - term memory loss. The delivery of health and personal care respected service users’ privacy and dignity. Relatives and friends were welcome to stay with service users and assist with their care if service users wished them to do so. The care approach and philosophy of care embraced and respected family relationships. Service users were registered with a local GP practice though they could choose to retain their own GP if prepared to visit them at the home if necessary. The home retains the services of a local GP who routinely visited the home weekly and at other times by request. Staff actively promoted service users’ rights to access health care services to meet assessed needs and maintain good health. The home continued to ensure robust pressure sore prevention arrangements and provision as necessary of pressure relieving equipment. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 13 The home has a sustained record of full compliance with standards and regulations for administration, safekeeping and disposal of medication. Observations confirmed the home’s medication policy, procedures and practice to be overall satisfactory. Significant variation in temperature records for cold storage of medication however was noted in one clinical room and drawn to the attention of management. The need for nurses to ensure this information is in future reported to management was discussed. Other areas of discussion included the small clinical room in the dementia unit, which was not fully fit for purpose. The manager confirmed that recent discussions regarding possible future reconfiguration of accommodation had considered ways for relocating this clinical room to a larger room. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Links with families and friends of service users and with the local community serve to enrich the lives of service users. The activity programme and arrangements for social care and stimulation were commendable. Mealtimes were relaxed, social occasions and staff assistance provided discreetly and sensitively. A varied menu was available affording choice of meals and soft and pureed diets were nicely presented. Service could choose to eat their meals in their bedrooms. EVIDENCE: The home’s ethos recognised the therapeutic benefits of being mentally and physically active whilst respecting service users wishes not to join in organised activities and social events. Discussions with management and staff demonstrated the contribution of relatives and friends to service users wellbeing was valued. Visitors were made welcome by staff on the day of the inspection visit. They could stay as long as they wished and have a meal with the person they were visiting by arrangement. Organised activities included a range of innovative reminiscence activities and suitable resource materials. The activity coordinator was responsible for producing a monthly programme, which was varied and responsive to service The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 15 users’ interests. Service users had access to a trained hairdresser who provided a weekly service in the home’s hairdressing salon. Aromatherapy and manicures were available. Provision included gentle armchair exercises to music, group and one to one activities, coffee mornings, poetry readings, art and crafts, music appreciation, bingo, quizzes, and visits from external entertainers. Excursions in the community had taken place involving relatives, staff and helpers since the last inspection. On the day of the inspection visit a large group activity took place in which service users enjoyed a sing-along to organ music played by a volunteer. A Pat-Dog also visited service users’ during the inspection, which was a regular event. Social occasions were frequently organised celebrating service users’ birthdays and diversity. Religious festivities took place and special menus and social activities arranged to mark these occasions. Local arrangements were made with various denominations for religious services and a communion service at the home and visits by the clergy. The adjacent school also invited service users to sports days and other social events. The Friends of the Bradbury Centre arranged outings and a variety of in-house entertainment and supported the home by raising funds for the benefit of service users. It was lovely to see displayed on a notice board and featured in the home’s activity programme, a service user’s written account of her visit earlier this year to a Buckingham Palace Garden Party. A photograph of this service user at Buckingham Palace and members of staff who accompanied her was also displayed. This individual informed the inspector that she had had a memorable day. Since the last inspection the head chef had resigned and the second chef was very recently promoted to the vacancy. A further change in catering arrangements had been the new provision of a supper chef, which was stated to have enhanced catering services. An imminent change to the home’s catering arrangements was planned. This will offer even more flexibility for service users in their choice of meals. At the time of this inspection a kitchen assistant consulted service users individually each day to offer them a choice of menu for the following day. The new system made provision of daily menus on dining tables and service users would be able to select from the menu at the time of meals being served. The manager stated that sherry and wine would also be available at meal times in addition to the usual soft drinks or water. The menu currently is a four weekly rotating menu with a choice of main meals. There was stated to be other alternatives if service users did not like either option. During contact made with a service user on an elderly frail unit the inspector noted this individual’s stated her moral preference not to eat meat. This information had not been communicated to the home by this individual at the time of admission but stated after her care plan had been written. It was noted that care staff were aware and tried to accommodate this person’s wishes by removing meat from her plate but the chef not aware and The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 16 this information not recorded. It was noted that this individual’s care plan had not been reviewed since May 2006. The head of care and manager were requested at the time of this inspection to discuss and record the dietary preferences of this individual and to arrange for a vegetarian option to be offered if this was required. The chef was able to offer a varied and nutritious vegetarian menu. The meals served at mealtimes were substantial and appetising. Discussion took place with the manager on gaps in food probing records in the dementia units’ kitchen. This practice was necessary for chilled pureed meals after being heated in the microwave oven. The central kitchen was clean and hygienic and action had been taken for compliance with requirements and recommendations made by the Environmental Health Officer following a recent inspection. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had access to a robust, effective complaint procedure. Whilst appropriate safeguards were in place for responding to suspicions or allegations of abuse attention was necessary to an area of staff recruitment procedures to further enhance adult protection arrangements. The need to review procedures and policies to secure staff cooperation with multi-agency safeguarding vulnerable adult procedures was also discussed. EVIDENCE: Record keeping for complaints was satisfactory and the complaint procedure was transparent and operating effectively. The procedure was accessible to service users and their representatives. The process for complaint investigations ensured written outcome produced for complainants within statutory timescales. It was concluded on the basis of the information available that all complaints were taken seriously and any shortfalls in standards were acknowledged and addressed apologies extended to the complainant. Safeguarding vulnerable adult procedures were in operation and multi-agency procedures for reporting allegations were adhered to. The home’s management was clear of abuse thresholds for intervention. Since the last inspection there had been two referrals invoking local multi-agency safeguarding adult procedures. Both were unsubstantiated in that one of the allegations was later retracted and another could not be pursued. Discussed with the manager was the need to include in the current review of staff’s terms and conditions The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 18 whether these adequately covered staff’s obligations and duty of care to cooperate with safeguarding vulnerable adult protection procedures. It was suggested that this matter also be considered when reviewing the homes whistle blowing and disciplinary procedures. A policy statement could also be produced regarding the rights and obligations of staff and service users to work and live in an environment in which harassment or abuse is not tolerated. This was in the context of discussion about difficulties at times faced by international staff in the workplace. Staff training records demonstrated a rolling programme of statutory staff training specific to adult protection. Information about the organisation’s whistle blowing procedure was contained in staff handbooks and displayed in the staff room. Service users would be further safeguarded by the home’s staff recruitment procedures by adherence to the statutory requirement for POVA checks to be carried out for all new staff prior to taking up post. Whilst this statutory requirement was not met the risk to service users through this shortfall was minimised through the practice of ensuring direct supervision of new staff at all times until receipt of their Criminal Records Bureau Disclosure. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 design and layout of the physical environment was suitable for the home’s philosophy of care and stated purpose. Living units were domestic in character, clean and comfortable and promoted independence. The premises and grounds was secure and overall well maintained though attention was required to hot water temperatures in some areas. EVIDENCE: The premises offered a comfortable, domestic style environment suitable to meet the needs of older people and for provision of dementia care. In 2005 an additional two en suite bedrooms had been provided in a small extension with design features that included overhead tracking facilities for hoisting. Since the last inspection a small lounge had been converted into an ensuite bedroom providing an additional place for dementia care. This room was spacious and finished to a good standard. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 20 Aids, hoists and grab rails were available throughout the home, also orientating information to assist service users in finding their way around the home. The group living units were homely in their decoration and furnishings. The bedrooms sampled were suitably furnished and personalised. Bedrooms could be secured for privacy and the environment and external grounds was secure and safe. A programme of routine maintenance and renewal of the fabric and of redecoration was evidenced and hot water temperatures routinely monitored. This practice had identified a number of valves for regulating hot water temperatures to washbasins and baths to be in need of replacement. At the time of the inspection an immediate requirement was made for additional safeguards to be in place to minimise risk to service users of scalding. This action was immediately implemented. Requirement was also made for the necessary work to be carried out. The garden was well maintained and a new patio had been developed since the last inspection. The home was clean and hygienic throughout and odour control was effectively managed. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home were suitably qualified and trained, and in sufficient numbers to fulfil the home’s aims and objectives and meet the needs of service users. Whilst staff recruitment procedures were robust attention was drawn to the statutory requirement for new staff to be checked against the POVA list prior to taking up post. EVIDENCE: The manager confirmed that staffing levels were reviewed following the last inspection. The home was operating staffing levels in accordance with the former staffing notice and on some shifts exceeded these levels. The manager stated she had autonomy to increase staffing levels in response to any significant increase in dependency levels. Observations during the inspection visit indicated that staffing levels were adequate. Management encouraged staff members to undertake certificated qualifications beyond the basic requirements and recognised the benefits of a skilled, trained workforce. The roles and responsibilities of staff were clearly defined through accurate job descriptions and specifications. Individual service users and a number of visitors gave positive feedback about staff to the inspector. A service user commented, “staff are the best, they are good and I have no complaints”. The Bradbury Centre DS0000017595.V307170.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. These standards were met ensuring effective management of the home and provision of strong leadership and direction to staff. Management and senior staff created a positive, inclusive and supportive atmosphere. The home had effective quality assurance and monitoring processes. Management had no involvement service users personal finances. EVIDENCE: The home was being effectively managed and administered at the time of the inspection. The registered nurse manager was suitably qualified and the senior team provided consistent leadership and direction to staff ensuring service policies and procedures were followed. It was concluded that the management style operating in this home created an open, positive and inclusive atmosphere. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 23 Quality audit and monitoring systems were overall effective and external senior managers undertook statutory monthly visits. Areas of discussion with management included work necessary to ensure hot water temperatures in bedrooms and bathrooms are at a safe temperation. In the interim it is essential to closely monitor the risk management strategy implemented at the time of the inspection. It is also necessary to review the home’s fire risk assessment. The home’s staff did not handle money belonging to service users. Arrangements were in place to invoice service users or their representatives for additional charges including purchases from the in-house shop. The manager stated that service users were encouraged not to keep large amounts of money in their rooms. It was stated that there was a lockable facility in bedrooms for service users’ use. Records required by regulation were in place and well organised. Discussed was the need to ensure care plans are reviewed at least monthly. Statutory requirements for an up to date photograph of service users to be maintained was met. On the basis that this was held on medication records and care staff do not routinely have access to these records it is recommended that a photograph be also placed on care plans as an aid to identification. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 24 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 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x 2 2 The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 25 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 OP7 OP37 Regulation 15(1)(2) Requirement For records to demonstrate service users and/or their representative’s involvement in care planning where possible. Care plans must be reviewed at least monthly. For review of the home’s policies and procedures and of staff’s terms and conditions of employment to ensure staff work in partnership and fully cooperate with multi-agency safeguarding vulnerable adults procedures. For replacement of valves to baths and hand basins as necessary to provide hot water at temperatures close to 43 degrees C. In the interim for effective risk management strategies to be in place and closely monitored. For review of the home’s fire risk assessment. For new staff to not take up post before checks are carried out against the POVA list. Timescale for action 29/09/06 2. OP18 13(6) 29/09/06 3. OP19 OP25 13(4), 23(2)(b) 31/10/06 4. 4. OP19 OP38 OP29 23(4)(a) 19 15/09/06 01/09/06 The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP7 OP37 Good Practice Recommendations For a formal system to be in place for regular reviews of care plans involving service users where capable or as appropriate their representatives/relatives. For current photograph of service users to be held on care plans. The Bradbury Centre DS0000017595.V307170.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office 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 DS0000017595.V307170.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!