Inspection on 23/08/05 for Broadacres

This inspection was carried out on 23rd August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broadacres 18/04/07

Broadacres 04/01/06

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 NR12 8AR Lead Inspector Kim Patience Unannounced 23 August 9:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broadacres Address Hall Road, Barton Turf, Norwich, Norfolk, NR12 8AR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01692 630939 01692 630939 Mr Michael John Muir-Smith Mrs Daphne Gillian Muir-Smith Care Home 28 Category(ies) of OP Old age registration, with number of places BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 28 service users may be accommodated of either sex who are aged over 65 years. Date of last inspection 11 February 2005 Brief Description of the Service: Broadacres is a care home for the elderly 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 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. It is registered to accommodate 28 older people, however, is operating at a reduced level due to refurbishment of the original home. Completion of the refurbishment is planned for August 2004 and will result in all the rooms being fitted with en-suite facilities and the creation of a new dining room to the rear of the property. In the extension all rooms are single and have en-suite facilities. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately four hours to complete. The manager/proprietor was available throughout and helpful in facilitating the inspection process. During the inspection a tour of the premises was conducted, staff and service user records were inspected and the registered manager, care staff and residents were interviewed. A number of comment cards were left for residents and relatives to make comments about the service if they wish to do so. What the service does well: What has improved since the last inspection? What they could do better: The management must improve the recruitment practice and ensure that have read and understood the latest guidance issued by the Department of Health in respect of the protection of vulnerable adults. Staff must not commence work without the required pre-employment checks being carried out. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 6 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. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 N/A EVIDENCE: N/A BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10, This home can clearly demonstrate through its record keeping that residents health, personal and social care needs are well documented and met. People are treated with respect and their right to privacy is upheld. EVIDENCE: Three service user files were inspected. The records relating to each individual contain detailed information in respect of their overall care needs. Evidence of service user involvement in planning their care was seen by way of signatures. Health care needs are recorded and evidence of medical intervention could be seen. Residents are given a choice of GP but the majority are registered with the surgery in Wroxham. The GP offers a good service to residents and visits on a weekly basis. Each resident has a medical review once every six months at which time the GP provides a full health check and reviews their medication. Four residents were spoken to and each confirmed that they were treated in the manner that showed respect for them. Staff were described as caring and polite. Residents said that staff respected their right to privacy and would always knock before entering their room. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14, Residents contact with relatives and friends is promoted, as is choice and selfdetermination. EVIDENCE: The service user records inspected showed details of significant relationships that need to be promoted and maintained. The home is welcoming of visitors and impose no restrictions on visiting at reasonable times of the day. residents interviewed confirmed that they were able to receive visitors when they liked to and had not experienced any difficulties in this respect. The ethos within this home is one of promoting people’s rights and choices. Residents are provided with choices in respect of their daily living and these are clearly recorded in their individual plans. Residents interviewed discussed their daily routines and were happy with the way in which they were able to live their lives as they chose to, with the support of the staff working in the home. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The management have systems in place for people to make complaints and all complaints are taken seriously. The management has procedures in place that aim to protect people from the risk of abuse. EVIDENCE: The home has a complaints procedure that is included in the service user guide. Service users spoken to confirmed that if they had a complaint they would raise it with the manager without hesitation and feel confident that they would get a positive response. The home maintains a record of complaints however, has not received a complaint in the last 12 months. The home has a policy in place for the protection of vulnerable adults. Staff interviewed were aware of the policy, which included the whistle-blowing policy and had received training in adult protection. The home has not had any adult protection concerns in the last 12 months. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 This home is well maintained and provides accommodation of a high standard. The home has systems in place to ensure that the environment is kept clean, tidy and pleasant for people to live in. EVIDENCE: A tour of the premises was carried out and all areas were found to be clean and tidy. The home employs a small team of domestics and have recently appointed a head housekeeper. All domestic staff are trained in health and safety procedures that include infection control. The home is located in a rural setting with very pleasant surroundings. The accommodation provided is furnished to a high standard and communal areas are homely and nicely furnished. The rear of the home has extensive well-maintained grounds, on which many of the rooms look out to. Work to improve the accommodation in the original building is ongoing, but it is anticipated that the work will be completed in the very near future. The BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 13 management have made efforts to keep any disruption for resident to a minimum. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents needs are met by a well-trained team of staff, in such numbers that ensure peoples assessed needs are met to their individual standard. The management can demonstrate that residents are adequately protected through robust recruitment practice. However, they must ensure that this good practice applies to all staff appointed to work at the home regardless of the arrangements under which they are employed. EVIDENCE: The staffing levels were assessed through discussion with the manager, staff and residents and a copy of the staffing roster was taken. The home is accommodating 21 residents at present who, in the main, have low dependency needs. The shift patterns are arranged as 8-2, 2-9, 9-8, four carers are assigned to the early shift and three to the late shift. The home has one waking night staff on duty with the manager available on-call if needed. The care hours are in excess of the minimum requirement, which results in the provision of a good quality service that meets peoples needs and expectations. In addition, the home employs a head chef, an assistant to the chef and two server staff. As already mentioned in standard 19, there is a small team of domestic staff comprising of a head housekeeper and two domestic assistants. Staff and residents were spoken to and either expressed any concern relating to inadequate staffing. Staff working at the home are provided with good training and are given numerous opportunities to enhance their skills and knowledge through various BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 15 sources. The home has a training and staff development programme and have allocated a budget specifically to training. All new staff are required to undertake a 6 week induction programme which includes elements such as; introduction to the home and residents, health and safety, fire safety, policy and procedures and care practice. During the induction there is a period of three weeks shadowing and no-one is permitted to work alone until assessed by the manager as being competent to do so. All staff are provided with training that enables them to carryout their duties effectively. Evidence of training was seen and courses such as, medication training, optical awareness, adult protection, dealing with death and bereavement had been taken recently. In addition, mandatory training such as moving and handling, health and safety and fire safety had been completed. Staff records relating to new members of staff were inspected. Whilst good practice was seen in respect of the application and interview process, staff had been appointed and commenced work without a CRB or POVA being completed. However, those staff were appointed as trainees on a trial basis only in order to establish whether the role of care assistant is one that they are suitable for and one that they would want to continue with on a more permanent basis. The management had made arrangements to ensure that they did not work unsupervised at any time. When questioned, the manager thought that they were complying with the regulation and had misinterpreted the revised guidance in respect of the protection of vulnerable adults, provided by the Department of Health in July 2004. Clarification of the legislation was provided and the manager now has a clear understanding of the circumstances under which care workers can be employed. A requirement has been made in respect of this and the home is to ensure that all new staff appointed have a POVA and criminal records check without further delay. See requirements. BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 0 N/A EVIDENCE: N/A BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 N/A 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 3 14 3 15 N/A COMPLAINTS AND PROTECTION 3 N/A N/A N/A N/A N/A N/A 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 Standard No 16 17 18 Score 3 N/A 3 N/A N/A N/A N/A N/A N/A N/A N/A BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 19 Requirement The registered person must ensure that the home operates a thorough recruitment procedure that ensures the protection of residents. This refers to the requirement to carry out a CRB and POVA check prior to staff commencing work. Timescale for action Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 BROADACRES I55 S27526 Broadacres V245981 230805 Stage 4.doc Version 1.40 Page 20 - 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!