Inspection on 12/11/07 for Broad Oaks

This inspection was carried out on 12th November 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broad Oaks 16/11/09

Broad Oaks 11/10/06

Broad Oaks 20/01/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Broad Oaks 30 Gaul Road March Cambridgeshire PE15 9RQ Lead Inspector Nicky Hone Key Unannounced Inspection 12th November 2007 11:30 Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 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 Broad Oaks DS0000063390.V354642.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 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. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broad Oaks Address 30 Gaul Road March Cambridgeshire PE15 9RQ 01354 656022 01354 656934 broadoaks@schealthcare.co.uk Not available Active Care Partnerships Ltd 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) Mrs Melissa Renee Whymark Care Home 38 Category(ies) of Dementia (1), Learning disability (38), Learning registration, with number disability over 65 years of age (15) of places Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th October 2006 Brief Description of the Service: Broad Oaks is a care service for people with learning disabilities. The service consists of four bungalows, two blocks of four flats, and a resource centre. The home has accepted groups of people with a wide range of needs, and covering a great age range: two of the bungalows have groups of much older residents, several of whom are over 65 years of age and one bungalow offers a home to young adults who are between 19 and 25 years of age. Built around a central courtyard, and backing onto a small estate of new houses in a residential area of March, the bungalows and flats blend in well with neighbouring properties. Each bungalow consists of single bedrooms all with ensuite toilet and washbasin, a kitchen/dining room, lounge, laundry, bathroom, shower room and cloakroom. The flats are in blocks of four, each for two people, with two bedrooms, bathroom, living room and kitchen. An additional building on the site, the leisure and education centre, contains offices and rooms where a range of activities can take place, both during the day, during the evening and at weekends. There is an art room, a sensory room and a large room which houses a piano and an organ. This room can be divided into two. There is also a kitchen, and toilet facilities. Adjacent to a public recreation park, Broadoaks is situated about five minutes walk from the centre of the busy market town of March, which offers a range of shops and leisure facilities. The home is within easy driving distance of Peterborough which has additional leisure facilities such as bowling and iceskating. All of the people who live at Broadoaks are funded by local authorities/care trusts. The fees are quoted in the service user guide and range from £694.02 to £1546.39 per week, based on the amount of care and support needed by each person. A copy of the inspection report is available in each bungalow and each block of flats, and in the reception area of the resource centre. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For this inspection we (the Commission for Social Care Inspection) looked at all the information that we have received, or asked for, since the last key inspection of Broadoaks. This included: • The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in September 2007. The AQAA is a selfassessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live there. The AQAA also gives us some numerical information about the service; Surveys which we sent to people who live at Broadoaks, and to their relatives/carers. We received a total of ten replies. Some of the comments from the surveys, and some of the results are quoted in the summary and in the body of the report; What the service has told us about things that have happened at the home, these are called ‘notifications’ and are a legal requirement; and Reports sent to us by the provider following monthly visits they make to the home. • • • This inspection of Broadoaks included an unannounced visit to the home on 12/11/07. During our visit we spoke with several staff and the manager, and looked at some of the paperwork the home has to keep. This included assessments, care plans, medication charts, and records such as staff personnel files, rotas, and fire alarm test records. What the service does well: Overall, this home continues to offer a good service to the people who live here. All the relatives who responded to our survey were very positive about all aspects of the service. These are some of the comments they wrote: “In my opinion the home does very well looking after all residents. Just tell them to keep it up and many thanks”; “They are very supportive in every way for all the clients”; “We are very pleased with the service he receives”; Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 6 “When we go to see our relative it is like a home from home. Everyone is very friendly and caring”; “I always find everyone very kind and helpful with lots of patience”; and “My relative is very happy there so that must say something. She is well looked after”. Residents who wrote to us also seemed quite satisfied with the home. The atmosphere in the bungalows we visited was good, with staff and residents clearly enjoying each other’s company, and treating each other in a friendly, respectful way. Good information about the home is available for everyone, including new residents, and full assessments of each person’s needs are carried out before the person is offered a place. Information in care plans about the way people want to be supported is good in most cases, and we saw that people’s healthcare needs are met. Most people have opportunities for personal development and leisure activities (see ‘What they could do better’ below), with the majority of activities being found in the local community, rather than being organised at Broadoaks. People have confidence that their complaints will be listened to and acted on. Staff understand and know how to report any suspicions of abuse. The bungalows seen were very clean, smelled fresh and were nicely decorated. There was lots of evidence that people are encouraged to make this their home, with personal possessions in abundance in some of the rooms. Staff have worked hard to make sure people have all the personal items they want in their rooms. In the Lodge, this includes numerous sensory items such as lights, holographic objects and soft fabrics. Staff recruitment is done well and the home is almost fully staffed. Staff said that most of the time there are enough staff, although more individual work would be possible if staff numbers were increased. The manager is looking at the way staff hours are used in order to resolve some of this. Training opportunities are good and a high percentage of the care staff will have a National Vocational Qualification in care, level 2 or above, by the end of 2008. Residents’ views are taken into account at every opportunity, and quality audits are carried out every month. A representative of the provider visits at least monthly and produces a report (as Regulations say they must), and a copy is sent to CSCI. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 8 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 Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 People who use this service experience good quality outcomes in this area. New residents have good information about the home, and can be confident that their needs have been assessed before admission, so that staff know the support they need. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Broadoaks has produced a statement of purpose and service user guide. These are kept up to date and can easily be found in each bungalow, with additional copies in the reception area of the resource centre. We looked at the records the home keeps for three people who live there. We saw that a full assessment of each person’s needs is carried out by the person’s care manager so that the home knows what support the person needs. Staff from Broadoaks go to meet the person and find out more about them, before they are offered a place. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 People who use this service experience good quality outcomes in this area. Most care plans have good enough information for staff to know how to support that person properly. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at several care plans. The manager explained that there were three different formats: the one that had been in use before the manager went to work at another home; one that was introduced while the manager was away; and a third which was being introduced at the time of our visit, because the manager felt it would be better. We discussed with the manager that it isn’t always the format that is important, but what is written in the care plan, the way it is written, and whether the information is a useful tool for the staff. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 11 One of the plans we looked at included very good detail about how the person wants to be supported in all areas of their life. Some of the words and terms used were rather ‘academic’ and might not be those which the person themselves would use or understand. A care plan we saw in the Lodge was very good: the information was very positive and the guidelines for staff were clear. This plan included detailed risk assessments about all aspects of this person’s life. This person has a ‘switch’ system which he uses to indicate his likes and dislikes. We looked at a care plan in one of the other bungalows. This plan was about a person whose health had recently got worse, and who now spends some days in bed. The plan included a ‘pen picture’ which was not dated or signed, but was clearly not showing the person’s current situation. Some of the individual care plans had started but needed more detail to make them useful. For example, the plan for eating and drinking stated “X is fully assisted when eating and drinking, at all times, by staff”. There was no detail about this person’s likes and dislikes; whether food should be fortified and if so how; whether this person can eat a normal diet or if the food needs to be soft or pureed; and so on. The ‘Living and Lifestyles’ section of this person’s care plan was very negative, focussing on things the person cannot do, with very little of what they can. There were a number of vague statements such as “to ensure X is getting the best of things”; “safe environment to be maintained”; and so on, with no detail of what this means for the person or what staff should do. (See also the Lifestyle section of this report). People who live at Broadoaks are supported and encouraged, with assistance from staff when needed, to make decisions about as many aspects of their lives as possible. Staff in all the bungalows try to make sure that people choose what, where and when they eat, when they get up and go to bed, where they spend their day, who they spend time with, and so on. People pursue individual hobbies if they want to and go on the holiday of their choice. There is an expectation at Broadoaks that people will join in as much of the life in their home as they want to. Meetings are held in each bungalow/flat for people to make decisions about what happens in their bungalow/flat. People are able to decide what takes place in the resource centre, and are encouraged and supported to join in activity and entertainment sessions if they want to. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 People who use this service experience good quality outcomes in this area. People who live at Broadoaks can choose from a range of activities and leisure opportunities, both at the home and in their local community. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We spoke with one resident who told us she likes living at Broadoaks. She has guinea pigs and rabbits in the garden which she looks after, and she goes to a local centre where she helps to care for the animals. Unfortunately we learnt that she is no longer able to go horse-riding because of a problem with insurance. The manager is trying to resolve this. In the bungalow where all the residents are under 25 years of age, a lot of activity is arranged. Each person has a plan of the activities they would like to do each week. On some days, some people go to day services which are Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 13 organised by other providers. One of the staff we spoke with said all the staff who work in this bungalow are very good at making sure the residents have very full, active lives. Another member of staff said “it’s fantastic what the home are doing for (name)”. Several people were in and out during our brief visit. Staff said there are not always enough staff for everyone to go out (as four people use wheelchairs), and a vehicle is not always available, but they do as much as they can. In the summer all the people who live in this bungalow (5) and five staff went to Banham zoo for the day. They took a picnic and everyone had a great day. We looked at the plan for one person and saw that this person now has a trampoline, and a quad bike, and is a member of a local gym. In-house activities in this bungalow include massages, music, sensory lights, jig-saw puzzles, colouring, gardening and so on. In the other bungalow we visited, fewer activities take place. We saw one ‘Working, recreation and leisure’ care plan, which stated on 17/10/07 “to make sure X goes out more”. There were 14 entries on the activity record for this person for 2 weeks in October/November: 13 of the entries recorded that this person had “relaxed at home/on bed/in dining room”. There was only one entry (“went into town shops”) which showed the person had been out. (See also the Individual Needs and Choices section of this report). The manager told us that since her return to Broadoaks she has decided to take responsibility for organising and coordinating activities across the whole site. This should mean that more opportunities are made available for people. For example, staff take one person from one of the bungalows to a day service near Cambridge which involves a bus journey of almost an hour each way. Instead of two staff (driver and escort) just taking this one person and driving back, then returning to collect them later in the day (four hours driving in total), they could perhaps take other people from the other bungalows/flats who would like to spend the day doing something in the area before picking the first resident up from their day service and coming home. This would not only give residents more opportunities, but would also be more interesting for the staff. In our last report we wrote: “Families and friends are welcome at the home whenever residents want to see them. When needed, staff support people to keep in touch with, and visit, their friends and families. People are supported, if they need and want the support, to develop personal relationships. The daily routines in each bungalow/flat are designed with input from the people who live in them, to enable each person to be as independent as possible. Residents know they have responsibilities, such as assisting with the household chores as much as they are able to. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 14 There are no set menus in the bungalows or flats. Each of the bungalows and each of the flats have their own household budget, and each group decides each week what they would like to eat. Residents help with writing the shopping list, doing the shopping and preparing the meal if they are able to. We saw a record of meals that had been provided: this showed that people have a good variety of generally healthy, nutritious meals, as in any household.” In the AQAA the manager indicated that this all still applies, so did relatives and residents who replied to our survey. From our observations on the day of this inspection, we feel the home manages these areas well. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use this service experience good quality outcomes in this area. Healthcare needs are met and medicines are dealt with well so that people keep as well as possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There was evidence on the care plans we saw to show that people’s healthcare needs are met. The chiropodist, doctor and district nurse had all visited. One person had developed a small pressure sore which had been treated by the district nurse and had healed. A special mattress had been put on the person’s bed, and this person now has a special recliner chair in the dining room. We looked at the way medicines are handled in two bungalows. We noted that both cupboards were neat and tidy and the records of the way each medicine has been handled (received into the home, administered to the person, and any excess disposed of), were good. Protocols on the way some medicines (for example, rectal diazepam) have to be given to certain people are kept up to Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 16 date and are kept in the medicine cupboard as well as in the person’s file. In this way the instructions are immediately available to staff in an emergency. Lockable cupboards for controlled drugs have been fitted in the bungalows and flats where controlled medicines are used. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use this service experience good quality outcomes in this area. People who live at Broadoaks are confident their concerns will be listened to and acted on, and that staff know how to protect them from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a complaints procedure which is on display in each of the bungalows and flats, and is included in the service user guide. There have been no complaints made since the last inspection. People who responded to our survey said they would speak to any of the staff or the manager if something were not right. One relative wrote “When there has been a complaint it has always been dealt with at once”. The manager said that staff have been on training courses to make sure they understand and know how to protect the residents from abuse (called safeguarding adults). One senior member of staff has done some training with Cambridgeshire County Council so that she can be a ‘key practitioner’. This means she will soon be qualified to train other staff in safeguarding adults. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 People who use this service experience excellent quality outcomes in this area. Broadoaks offers the people who live here a comfortable, homely, clean place to live where they are supported to be involved in making this their home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each of the four bungalows at Broadoaks has a lounge, a dining room/kitchen, a bathroom, a shower room, a toilet and a laundry. Every bedroom has an ensuite toilet and washbasin. On this visit, we saw two of the bungalows. Both were very clean and there were no bad smells anywhere. Generally both bungalows were very nicely decorated, well maintained, and homely in the way they are furnished. We noticed that the lounge carpet in one bungalow was stained and some of the Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 19 furniture is beginning to look worn: the manager and staff said that new carpets and furniture have been ordered. A lot of decorating has taken place since our last inspection, and some new carpets fitted. The manager gave us a copy of a decorating/maintenance plan which has been drawn up to ensure all areas of the home are decorated on a rolling programme. Staff get involved in decorating and in making the bungalows feel homely and welcoming. Each resident’s bedroom is decorated in the way that person wants it, and staff support people to decide what they want in their room. Bedrooms in the Lodge (the bungalow for younger people) have various sensory items in them, such as lights, soft fabrics, mobiles and holographic objects, according to what each person likes. Each bungalow has its own enclosed back garden. Staff in the bungalows, and some of the residents, help to look after the gardens, and introduce items to interest the residents. One resident has his own greenhouse. The flats (which we did not visit this time) each have two bedrooms (with washbasins), a lounge/dining room and small kitchen, and each flat has a bathroom or shower room which is shared by the two occupants. The manager said that some decorating has taken place in the flats since our last inspection. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 People who use this service experience good quality outcomes in this area. People are supported by staff who are well recruited, well trained and well supported to make sure they can do their jobs well. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In response to our survey one relative wrote “The staff treat each resident as an individual and care for their personal needs. All the staff are extremely friendly”. Rotas show that there are 16/17 support staff on duty in the mornings, and 15 in the afternoon/evenings, plus staff who are doing one-to-one hours with the residents. At night there are 7/8 staff, plus one of the day staff starts at 06.00. The senior staff team is made up of the manager, deputy manager, team leaders and deputy team leaders. There is always at least one of these people on site, including during the night, and one of them is designated ‘site leader’. The manager told us that there are only three full-time vacancies: when these are filled the home will be fully staffed. Agency staff are now used Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 21 very rarely (3 shifts since August) as permanent staff are willing to work extra shifts. We spoke with several staff who all said that on the whole they enjoy working at Broadoaks, and usually there are enough staff on duty. One person, who has worked at the home for about six months, had not been able to do all the required training, but is booked on to courses in early 2008. She has had oneto-one supervision with a manager/team leader. The manager said that training opportunities for staff are much better since the home was taken over by Active Care. The majority of staff have done all the courses needed, or are booked onto courses in the new year. In the AQAA the manager said the home is going to implement a more robust and structured induction programme for new staff in 2008. From the figures in the AQAA we know that 33 of the 80 care staff who work at Broadoaks have been awarded a National Vocational Qualification (NVQ) level 2 or above, and another 26 staff are working towards this qualification. The manager said she hopes all the rest of the care staff will be registered for an NVQ in 2008. One of the care plans we saw included a review, carried out on 03/10/07 by the person’s care manager (social worker). This indicated that there had been some problems at Broadoaks with the support given to staff, resulting in the support for the residents not being as good as it should have been. Staff we spoke with said this had been the case, but the problems had been resolved. One person’s relative had written to say that the culture (staff’s attitude) was improving, and staff were more pro-active, spending more time with the residents, especially at mealtimes. Records showed that staff now receive regular supervision. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41, 42 People who use this service experience good quality outcomes in this area. Overall, the home is managed well so that people have a good quality of life. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: In our last report we wrote, “This home runs well. It has good leadership and a staff team who are committed to providing a high standard of service, in partnership with the service users who live here”. Our evidence shows that overall this is still the case. We are confident that now the manager has returned, any hiccups that occurred in her absence will be resolved. The manager has returned with renewed enthusiasm and determination to keep moving this home forward. Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 23 Staff said the management of the home is good and they feel supported. In the AQAA the manager said that there is a system of monthly audits which are carried out to make sure the quality of the service remains high. There is also a system for regular consultation with the people who live at the home, to make sure their views are taken into account. All homes have to get information about new staff before they start work, to make sure they do not employ people who should not work with vulnerable adults. We looked at the file of one person who started work at Broadoaks since our inspection in 2006. All the information was in the file, and very neatly filed so it was easy to find. Several residents keep a small amount of their money in the home’s safe. This is dealt with from a small office, as if the office were a bank. There are opening and closing times (for banking) so the residents know when they can get their money. Records were not looked at on this occasion. Records of maintenance checks carried out are well organised. They showed us that regular checks are carried out on the fire alarm and emergency lighting systems in all areas of the home. Each time the fire alarm goes off or is being tested, staff and residents are expected to respond as if there were a fire. These fire drills are recorded. When we visited the Lodge we were told that there was a problem with the heating. The boiler had broken down. Portable heaters (with warning signs on them “hot surface do not touch”) had been put into all rooms where they were needed. However, no risk assessments had been completed. Staff explained this might have been because the engineers had said the problem would take three days to fix, but the parts had not been available. The problem had been going on for eleven days when we visited. Staff said they would carry out risk assessments immediately. Broad Oaks DS0000063390.V354642.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 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 3 28 4 29 3 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 2 X Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 13(4) Requirement Any risks to people who live at Broadoaks must be identified, assessed and so far as possible eliminated, so that people are safe from harm. Risk assessments must be carried out on the portable heaters in the Lodge. Timescale for action 12/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broad Oaks DS0000063390.V354642.R01.S.doc Version 5.2 Page 27 - 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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