Inspection on 04/01/06 for Broadacres

This inspection was carried out on 4th January 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

Broadacres 18/04/07

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 Kim Patience Unannounced Inspection 4th January 2006 09:50 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.V269887.R01.S.doc Version 5.0 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.V269887.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadacres Address Hall Road Barton Turf Norwich Norfolk NR12 8AR 01692 630939 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) Mr Michael John Muir-Smith Mrs Daphne Gillian Muir-Smith Mrs Daphne Gillian Muir-Smith Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 28 service users may be accommodated of either sex who are aged over 65 years. 23rd August 2005 Date of last inspection 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 DS0000027526.V269887.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately 5 hrs to complete. During the inspection, the manager and proprietor were available for consultation and were helpful in facilitating the process. Three service users were interviewed and members of staff were spoken with. Observation of interaction between staff and service users was made, along with an inspection of records relating to staff, service users and those relating to the running of the home. Service users, relatives and other stakeholders were surveyed and the results of the surveys are incorporated in the body of the report. On the 15th December 2005, the inspector had the opportunity to conduct a joint visit with the environmental health officer at which time a health and safety inspection was completed. Information acquired from this inspection is incorporated in standard 38. What the service does well: What has improved since the last inspection? Since the last inspection, the new dining room has been completed and is now in use. The dining room has been built and furnished to a high standard and provides a pleasant area in which to take meals, with panoramic views across the rear garden and the lake. The issues with recruitment of new staff have now been resolved and the management have up to date knowledge of best practice in this respect. In addition, the management have implemented systems in to ensure that good recruitment practice is maintained. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 6 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. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 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.V269887.R01.S.doc Version 5.0 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 the following standard(s): 3, 6 The home has systems in place to ensure that they are aware of peoples needs and that those assessed needs can be met when admitted to the home. The home has systems in place to ensure that people who require intermediate care are provided with a plan of rehabilitation that supports a return to independent living. EVIDENCE: The pre-admission process was assessed, two residents who were admitted recently were interviewed, and their care records were inspected. Records showed that before any person is admitted to the home their needs are assessed. The pre-admission assessment contained basic essential information about their care needs and enabled the home to assess whether they have the capacity to meet their needs. One resident spoke of the manager visiting him at home to discuss his needs and his relatives were involved in the assessment. Following the assessment Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 9 he was invited to visit the home to view the accommodation and meet with other residents. During the visit, he was invited to stay for the main meal and sample the food. Another resident spoken with preferred to visit the home with her relatives and during the visit, her needs were assessed. Both residents expressed satisfaction with the pre-admission process and felt that they were provided with sufficient information about the home and services offered to make an informed decision about moving in. Intermediate care is provided at the home for hospital discharges and for respite care. People referred for this service are provided with the same preadmission procedure as stated above. However, those discharged from hospital for short-term care may not have the opportunity to visit and view the accommodation and services. In addition to the pre-admission assessment, the home prepares a plan of rehabilitation, commissioning the services of a physiotherapist and occupation therapist where necessary. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The medicine administration practice at the home protects the health and welfare of its residents. EVIDENCE: The medicine storage, records and administration procedures were inspected and the person in charge was available for a discussion in respect of the procedures used. The home has a policy and procedure on the receipt, storage, handling, administration and disposal of medicines. Medication is stored appropriately in a treatment room and medication taken out for administration is transported in a lockable trolley suitable for its purpose. Records of medicines received, administered and disposed of are maintained and upon inspection were found to be in good order. Medicine administration records were completed for each service user, again, found to be in good order with no apparent errors. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 11 The home did not have any resident requiring a controlled drug at the time of inspection. However, the home has a metal cabinet that meets the requirements of the ‘misuse of drugs (safe custody) 1973’ regulations and a controlled drugs register. Medicines are administered by the person in charge on each shift and each authorised person has received regular training in order to complete the task effectively. The last training session was held at the University of East Anglia two weeks previous. A member of staff was observed to administer medication during the inspection and demonstrated good practice. Medicine administration practice is monitored and the records are checked by the manager/proprietor to ensure that good practice is being maintained. During the inspection a local GP arrived to review the medication for each of his patients and does so on a 6 monthly basis. Service users spoken with confirmed that their medication was administered using the correct procedures and at the appropriate times. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 The home has made efforts to provide activities for people living at the home, however this needs further development. The home makes efforts to meet people’s needs in respect of providing a wholesome healthy diet. However, the home needs to consult with service users to ensure they continue to improve the meals and meet individual expectations. EVIDENCE: The home employs an activities coordinator and an entertainment coordinator who have specific roles. The first deals with the planning and coordination of in house activities and the second deals with entertainment outside of the home such as, outings. A programme of activities has been developed and includes bingo, craftwork, exercise to music and quizzes, in addition to various others. Each person in charge is responsible for implementing the plan, however, residents spoken with stated that the activities advertised, are often cancelled and therefore they are less motivated to attend. When discussed with the manager, she said that staff attempt to deliver the programme of activities, but when there is a very poor attendance a decision is made to cancel the event. The manager has put measures in place to monitor the activities and attendance and staff are Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 13 required to complete an activities book to demonstrate that they have offered activities and record who attends and who has refused. The programme of activities is developed from individuals expressed interests, which are recorded on their care plans. Residents meetings are held on a quarterly basis and residents are invited to discuss the activities they would like to be offered. Minutes of the meetings were available and showed that this item had been discussed. It is recommended that the home consults with all residents and staff and agrees the best way to provide activities that are of interest and that people are motivated to attend. See recommendations. The meals provided at the home were assessed through discussion with the chef, inspection of the menus, information taken from records relating to service users and conversations with service users. The chef has over 20 years of experience working in various catering settings and has recently completed a food hygiene course. He has one kitchen assistant and two server assistants. Menus are prepared on a three weekly basis, they include seasonal changes and show that a variety of food is offered over the week. At breakfast, people are provided with a wide range of choices, two main meal options are available and alternatives are offered. At teatime, again there is a wide variety of choice. The Chef said that fresh fruit and vegetables are available on a daily basis, however one service user stated she had asked for fresh fruit and had not received any. Another service user confirmed that fresh vegetables were provided and she always enjoyed them. She also stated that fresh fruit is not always available. The chef visits each resident daily to tell them what is on the menu for the following day, to discuss alternative if needed and to take their order. Orders for each individual are recorded on a menu sheet, which clearly shows the diet of each individual. This is good practice and allows the home to monitor any changes in diet and health. A nutritional needs assessment is completed for each resident on admission and the information is passed to the chef so he can cater for any special dietary needs. One resident requires liquidised food and this is prepared in separate portions to make it as appealing as possible. Three residents require a diabetic diet and the chef demonstrated good knowledge of how to cater for these people. The quality of the food is monitored by requesting feedback following each meal and recording comments on a quality assurance form. In addition, meals are on the agenda at residents meetings and people’s preferences are taken into account when planning the menus. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 14 Some residents spoken with expressed dissatisfaction with the meals at times, however, others spoken with said that the food was very good and they enjoyed the meals. Service users surveys indicated that the majority were satisfied. The home needs to continue to monitor the quality of the food and perhaps devise a survey specific to meals so that residents can comment anonymously if they wish. See recommendations The new dining room is now complete and in use. This provides a lovely setting in which to dine with views out to the rear garden and lake. The room has been built and furnished to a very high standard and the residents are very pleased with the result. The tables were nicely laid out, in a way that provides privacy for those that prefer it and small social groups for others. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 15 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): 0 NA EVIDENCE: NA Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 16 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): 19,26 The management show commitment to providing a safe well-maintained environment, with systems in place to ensure that it is kept clean and tidy. EVIDENCE: The home is located close to the quiet rural village of Barton Turf, situated in its own substantial grounds. There is a car park to the front of the building and gardens to the side and rear providing a pleasant view from the resident’s rooms. The management have an active plan of maintenance and renewal. The refurbishment of the original house is almost complete, providing residents with refurbished rooms and en suite facilities and the new conservatory dining room has been completed, as described in standard 15. The home is maintained and furnished to a high standard providing residents with a safe environment in which to live. Two housekeepers are employed to maintain good standards of cleanliness and hygiene. On the day of inspection, the home was clean and tidy in the areas Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 17 visited and residents were pleased with the standard of cleanliness in their rooms. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 18 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): 29 The home has systems in place to ensure that the recruitment of new staff is robust and strives to protect vulnerable people. EVIDENCE: At the last inspection, there were concerns about the homes employment practice. This has been resolved and the home has systems in place to ensure that before employing new staff the necessary pre-employment checks have been completed. The staff files relating to two new members of staff were inspected and found to be in good order. An application form had been completed, the candidate had attended a face-to-face interview and those offered employment had completed a criminal records check and two written references had been taken up. The files contained a photo of the member of staff and evidence of identification. Each file also contained a file audit checklist to ensure compliance with the regulations and that no part of the recruitment process is overlooked. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 38. The management have some quality assurance mechanisms in place, however there is a need for a complete quality assurance system that includes consultation with stakeholders. The home does not assist any residents with their finances. The home has systems in place that promote the health, safety and welfare of staff and service users. EVIDENCE: The home has various systems in place to monitor the quality of the service such as, audit checklists for staff files, infection control checklists in communal toilets, quality monitoring forms for the meals served and residents meetings. In addition, there is an annual development plan that addresses improvements in the environment, staffing and care. However, there is no recognisable quality assurance system in place and this needs to be developed, along with Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 20 mechanisms for consultation with stakeholders. All service users need to be surveyed annually to seek their view about the quality of the service offered. It is essential that the management develop a quality assurance system that is a continuous process of identifying deficits in service and areas for improvement. Action plans can be drawn up using this information to demonstrate that the home is committed to the continuous improvement of the service. The results of the quality assurance process must be published and a copy made available to service users and the Commission. See requirements. At the time of inspection, the management were not supporting any service users with their financial affairs, therefore this standard is not applicable. The home has recently been inspected by environmental health officer and by the fire safety department. The inspector was present for part of the environmental health inspection and was able to see that the home has good systems in place to ensure the health and safety of people living and working in the home. Risk assessments are completed on the environment and the individuals. The home has a policy and procedure on health and safety and all staff are trained in this respect. The environmental health officer had no significant concerns about health and safety in the home and made one recommendation about the use of a ‘risk rating score’ and two statutory requirements for ‘working at height’ and ‘asbestos at work’. The fire safety inspection was completed on the 9/12/05 and the requirements and recommendations from the subsequent report have been addressed. Fire alarms are checked on a weekly basis, there is a procedure for evacuation in the case of a fire and all staff are trained in fire safety at least once every six months. There is a procedure in place for the testing of small electrical equipment, performed annually, and the emergency lighting and the nurse call system are tested monthly. Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 4 X X X X X X 4 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 24 Timescale for action The home must have an effective 31/03/06 quality assurance process in place that includes consultation with stakeholders and an annual internal audit. The results of which must be published and made available to stakeholders and the Commission. Requirement 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 OP12 Good Practice Recommendations It is recommended that the registered person consult with service users to ensure that the programme of activities meets their expectations and consult with staff to ensure activities are provided as planned. It is recommended that the registered person consult with individual service users about the quality of the food and seek to improve the meals where people are dissatisfied. 2 OP15 Broadacres DS0000027526.V269887.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Norfolk Area Office 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. 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