Inspection on 18/04/07 for Broadacres

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Broadacres 04/01/06

Broadacres 23/08/05

Broadacres 11/02/05

Broadacres 09/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Broadacres Hall Road Barton Turf Norwich Norfolk NR12 8AR Lead Inspector Maggie Prettyman Unannounced Inspection 18th April 2007 09:30 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 Broadacres DS0000027526.V336623.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. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadacres Address Hall Road Barton Turf Norwich Norfolk NR12 8AR 01692 630939 F/P 01692 630939 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) www.broadacres.co.uk Mr Michael John Muir-Smith Mrs Daphne Gillian Muir-Smith Shirley Ann Ellis Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4th January 2006 Brief Description of the Service: Broadacres is a care home for older people situated 6 miles from Wroxham in the broads village of Barton Turf. At the front of the property is a car park and to the rear is a large well-maintained and accessible garden, which backs onto Barton broad and has its own lake. The home is an adapted building to which a purpose built extension has been added. All residents’ rooms are en suite. The current range of weekly Fees is £459 - £510. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. This inspection took place over the course of one day. Prior to inspection the manager completed a pre inspection questionnaire and gave supporting documentary evidence. The inspector also received 29 survey forms returned from people living at the home and their relatives. A feedback form was also received from a GP who visits the home. During the inspection a complete tour of the building was conducted and people who live and work there were consulted in private. Visiting friends and relatives of people living at the home were also asked their opinion of services and support provided. What the service does well: Broadacres is an excellent home, which offers support to people in a caring, professional and dignified way The home is managed in an open and friendly manner, and procedures are in place to involve people in the running of the home. People are assessed before coming to the home, and once there have their health and personal care needs well supported, with structured plans of care in place. People feel treated with respect at all times and their privacy and autonomy is supported. People are helped to retain contact with their family and friends and meals are appetising and well balanced. Complaints and comments are listened to and acted upon, and properly trained and vetted staff look after people well, and protect them from abuse or harm. The building is exceptionally well appointed and maintained. Shared facilities are homely and comfortable. Bathing facilities are in each individual bedroom, with a properly maintained whirlpool bath available for use. Extremely high standards of cleanliness and hygiene are demonstrated throughout the home. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 6 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. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people to use this service and their representatives have the information they need to choose the home, and peoples’ needs are assessed prior to coming to live at the home. EVIDENCE: A detailed and up to date Service Users Guide was present in the home. A website in development was seen by the inspector, and the manager stated that she takes a laptop on visits to people looking to come to the home to show them photographs of the home’s facilities including the room identified for them. People living in the home and their relatives confirmed that information given to them during this process was informative and accurate. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 9 Inspection of records held for people living in the home demonstrated that a needs assessment is conducted by the manager or her Care Manager prior to people coming to live there. Discussion with people living in the home confirmed that they are involved in this process. The manager stated that the home does not offer intermediate care. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The principles of respect, dignity and privacy are put into all elements of daily practice, and the health and personal care that people receive is based on their individual needs and choices. EVIDENCE: Inspection of individual records demonstrated that a plan of care, including risk assessments, is in place for everyone living in the home. These plans were signed by the person receiving the service and evidence of regular recording and review was seen. People living in the home confirmed that they are consulted about the way in which their care is delivered. The home is in the process of developing a better system of handover that does not compromise people’s data protection rights. A recommendation has been made in this respect. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 11 Examination of people’s individual records demonstrated that their health is promoted and maintained. Risk assessments for tissue viability are in place, as well as nutritional screening and monitoring. Records demonstrated that GPs visit the home regularly. A feedback form from a visiting GP confirmed that heath care provision is good. The inspector saw the medication system. Some people remain selfmedicating, and risk assessments and records are in place for this. Records demonstrated that peoples’ drugs are reviewed with the GP twice a year. MAR sheets are generally regularly and accurately completed. Records of monthly drug audits were seen, but these do not include a recorded audit of MAR sheet completion. A recommendation has been made in this respect. Discussions with people living in the home during the inspection, as well as feedback sheets received, demonstrate that they feel treated with dignity and respect and that their privacy is maintained at all times. People have individual telephone lines in their rooms if they wish, names of choice are used at all times and clothes are individually labelled and carefully washed and ironed. One person said “ They are all so polite and friendly, I feel that my room is my private place.” Another said “They always knock before they come in and I have a sign I can put on the door if I do not wish to be disturbed.” The home has provided end of life care as appropriate this year. The new care manager is instituting a system of care based on the Liverpool Care Pathway to support people, their relatives and staff at this time. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The lifestyle of the home matches the needs and expectations of people living there; they exercise choice, keep in touch with their family, friends and community and enjoy good food in pleasant surroundings. EVIDENCE: Feedback from questionnaires and discussions with people and their visitors during the inspection demonstrated that the lifestyle of the home is flexible, comfortable and accommodates peoples’ individual choice and preference. The home has worked hard this year to develop an interesting, stimulating and appropriate range of activities, and is to be commended for this. One person said “ I have enjoyed the entertainment, outings and activities they have put on, it has made a real difference to me” Another said “I think it is really good that religious services are available for people from different denominations”. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 13 Observation during the inspection, as well as discussions with service users and their visitors demonstrated that people coming to visit the home are welcomed and made comfortable. Tea and coffee making facilities are freely available for visitors, and staff were consistently seen being positive and supportive to them. Service users confirmed that they maintain contact with the wider community. A person who has recently come to live at the home has continued to have a small group meeting in her room as she did when she lived at home. One person living in the home said “I come and go very much as I please, I have friends round for a drink if I wish, or I go out and stay out as late as I want to.” People consulted during the inspection said that they have maintained choice and control in their lives. Everyone living at the home manages his or her own financial affairs or has an external representative to do. The home does not hold money on behalf of any residents. The home has recently provided clear name badges for staff. People’s rooms are filled with personal possessions. Secure cabinets in each person’s room are used to store their individual medication. Care plans are in each persons room for freedom of access by them, and the manager said that she spot checks to ensure that that reviews are conducted in consultation with each person. The home has responded to suggestions from people who live there to improve the quality of food and the dining environment. A new dining room has been built which is spacious and comfortable. People said that they are given a daily choice of food, with alternatives provided if they do not like what is on the menu. Lists of individual preferences are maintained in the servery area. The new menu has been developed using dishes suggested by people living at the home. An enthusiastic and competent team in the kitchen were seen providing a well-presented and carefully cooked meal. Daily quality audit and feedback sheets are completed so that the manager can monitor the quality of food and the satisfaction of people eating it. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure. They are protected from abuse and have their rights protected. EVIDENCE: A record of complaints and action taken in response was seen during the inspection. Service users and their visitors said that their daily grumbles are generally listened to and changes made to rectify any problems. Records of regular resident and staff meetings were seen which demonstrated that issues raised are taken seriously and that appropriate action is taken. The home could benefit from auditing these issues and actions to identify any underlying patterns and trends in complaints, comments and compliments. A recommendation has been made to this effect. All staff consulted during the inspection, including domestic and catering workers confirmed that they have received training in adult protection. Training records supported this. The home has made appropriate POVA referrals in the past. Each person living at the home has space for secure storage of valuables. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21and 26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The design, layout and facilities of the home enable people who use the service to live in a safe and exceptionally well-maintained and comfortable environment. Great care is taken to maintain the cleanliness of the home and good laundry facilities mean that people’s clothes are well cared for. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 16 EVIDENCE: A tour of the premises demonstrated that the home is safe, tidy and is maintained to a high standard. The location and grounds are extremely attractive and the home and its gardens, are fully accessible. Improvements have been made this year to extend wheelchair access to the garden. Communal spaces in the home comprise of a lounge and a drawing room as well as several smaller intimate seating areas and an attractive new dining room. The premises are smoke free throughout. The gardens are carefully laid with improved wheelchair access. A new patio area is under construction and will shortly be completed. All areas of the home are attractively furnished in a warm and comfortable “country house” style. All bedrooms have ensuite bathing facilities with individual bathing aids as required by the resident. Lavatories are available near to lounge areas and a new lavatory for catering staff has been provided. In addition to individual facilities, the home has a whirlpool bath for use by residents. This is carefully maintained and detailed records of cleaning and sanitisation are in place. Service users commented positively about having access to this facility. The tour of the premises demonstrated that the home is spotlessly clean, pleasant and hygienic throughout. Cleaning audits demonstrated that this service is provided consistently. Domestic staff interviewed confirmed that they receive regular training and that they have the facilities and equipment to do their job well. This team is clearly hardworking and committed to providing an excellent service. The laundry has been upgraded this year and industrial machines ensure that a good quality service is provided. Bed linen is washed by an external contractor. The laundry was well organised with washing carefully sorted and arrangements in place for people’s clothes to be identified and returned to them in good condition. People who wish to continue doing their own laundry are supported to do so. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are carefully vetted and recruited to ensure that they are suitable for their jobs. They are trained, skilled and are in sufficient numbers to support the people who use the service. EVIDENCE: Rotas provided by the home, discussion with staff and observation on the day of inspection demonstrate that the home is staffed by suitable numbers of staff. Unplanned staff absence is covered by agency staff to ensure that people are not asked to work excessive hours. One resident said “They come on shift and are fresh and bright, and they stay that way until they go home.” Extra staff are employed at peak times or in case of extra care needs. During the inspection one person suggested that Agency workers be introduced to residents at the commencement of their shift. The manager agreed to implement this suggestion immediately. It was also suggested that a staff rota is made available to people who live in the home so that they know who is coming on duty. A recommendation has been made to this effect. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 18 Examination of training records demonstrated that the home continues to encourage staff to gain appropriate NVQ qualification from both care and domestic support teams. A selection of staff files were inspected. These demonstrated a good standard of recruitment and vetting, with many elements of good practice in place. Staff turnover has been increased over the past year, but a stable and competent team are now in place. Discussion with staff on duty as well as inspection of training records demonstrated that a good system of audited training is in place. Induction training is in place, with records demonstrating a structured and documented process, which meets current requirements and expectations. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38 People who use services experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect and has effective quality assurance systems developed by a competent and qualified manager. Staff receive regular supervision and safe working practices vare in place to protect people who live and work at the home. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 20 EVIDENCE: Throughout the course of the inspection the manager demonstrated clear and open management skills. The manager has gained her registration with the Commission since last April. The manager has direct financial control of the home and its resources. People who live in the home described the management style of the home as open and friendly. One person said, “ You can ask for anything and they will make sure that it gets done” Staff feel well supported and able to ask senior staff for help and advice. Regular residents and departmental meetings guide the direction and running of the home. Developments in the home over the last year demonstrate that the manager fully supports innovation and creativity. Since the last inspection a satisfaction survey has been conducted with people who live in the home. Results from this have informed and guided practice in the home, and have influenced the Investors in People development plan for the home. A wide-ranging system of quality audit is in place, which the manager is continuing to develop. The requirements and recommendations of the last inspection have been implemented, and copies of the report and ways of contacting the Commission are freely available in the hallway. The home does not handle money on behalf of people who live there. Records demonstrated that a new system of staff supervision and appraisal are in place. This includes both individual and team supervision, with focus on good practice and individual and team development. Inspection of safety and maintenance records demonstrated that the home is run with the health, safety and welfare of people who live and work there carefully considered. Mandatory training records demonstrated that staff are properly and regularly trained in this area. Hazardous substances are safely stored and detailed COSHH assessments are in place. Water temperatures are checked and regular fire drills held. The building is secure and the gardens and walkways are clear and even. Records demonstrated that the home complies with the various acts which govern Health and Safety at work. Risk assessments are in place. Accidents are carefully recorded, reported and audited Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X X X X 4 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 4 4 4 X 3 3 X 4 Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement 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. 2. 3. 4. Refer to Standard OP7 OP9 OP16 OP27 Good Practice Recommendations A system of handover should be developed that maintains good communication but does not compromise peoples data protection rights. The medication audit should include written records of MAR chart audit so that any omissions can be identified and investigated. An audit of minor complaints comments, suggestions and compliments should be kept so that any underlying patterns and trends can be analysed. A staff rota should be made available to residents so that they know who is coming on duty. Agency staff should be introduced to people at the beginning of their shift. Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Broadacres DS0000027526.V336623.R01.S.doc Version 5.2 Page 24 - 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!