Inspection on 29/11/05 for Broadfield House

This inspection was carried out on 29th November 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

Broadfield House 06/06/06

Broadfield House 28/03/06

Broadfield House 02/03/05

Broadfield House 26/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Broadfield House Broadfield Drive Leyland Preston Lancashire PR25 1NB Lead Inspector Della Lovell Announced Inspection 29th November 2005 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 Broadfield House DS0000035758.V254257.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. Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadfield House Address Broadfield Drive Leyland Preston Lancashire PR25 1NB 01772 422111 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) Lancashire County Care Services Mrs Wendy Cooper Care Home 45 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (14) of places Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 45 Service users to include up to 14 service users in the category of OP (Old age, not falling within any other category). Up to 31 service users in the category of DE (Dementia). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines that may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 16th August 2005 2. 3. Date of last inspection Brief Description of the Service: Broadfield is a well-established care home located in Leyland, which is operated by Lancashire County Care Services. There are shops and many other local facilities available nearby. The home has gone through an extensive refurbishment and building work and provides accommodation in four separate units within the home. The standard of the furnishings and fittings provided are of a high standard. The home is registered to accommodate 14 older people and 31 people who have care needs associated with a diagnosis of Dementia. One of the units in the home is designated to provide short-term rehabilitation services for people with dementia care needs. It is anticipated that the length of stay for people admitted to this unit will be for a period of up to twelve weeks. Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over one day in November 2005. The inspection involved discussion with the people who lived and worked at the home, examination of records, a tour of the home and information received from questionnaires sent to relatives and service users. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that assessments are undertaken for all service user admitted to the rehabilitation unit, which clearly identifies the outcomes and goals to be achieved. Care plans must provide the actions on how these outcomes and goals are to be achieved. The manager should review the homes risk assessments to ensure that staff are provided with instruction on actions to take to minimise any identified risks. Staff undertaking specific tasks such as risk assessments must be appropriately trained. The social and recreational activities in the home must be reviewed in accordance with the service users needs and expectations. Particular attention must be given to providing memory aids for service users suffering from dementia and improving staff awareness in this area. Staffing levels in the home should include time to meet service users social and recreational needs. Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 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. Broadfield House DS0000035758.V254257.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 Broadfield House DS0000035758.V254257.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 and 6 The admission and assessment process for service users admitted to the care home ensured that all needs were identified and met. However the assessment and admission process for service users requiring rehabilitation was not thorough enough to ensure that all individual needs where identified and met. EVIDENCE: All service users at Broadfield are referred through the Local Authority and a full assessment had been undertaken prior to admission. A number of files were checked as a part of the inspection process and assessments was kept on the service users individual file. Staff confirmed that they had access to the files and service users told the inspector that they had been involved in their admission to Broadfield and felt all their needs were being met. One unit at Broadfield provides rehabilitation to service users with dementia. At the time of the visit a conservatory was being built to provide additional lounge space, once this is completed additional space will be available for therapies and treatment. The unit was staffed by care staff from the home and external professional such as a social worker, occupational therapist and a physiotherapist. The registered manager told the inspector that the external professionals arrange the admissions and discharges and the team leader Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 9 manages the staff on the unit. It was of concern to the inspector that the registered manager had no overview with regards to the decisions made in relation to the care provided and the expected outcomes for the service users. There were no outcomes and goals noted for one service user who had been recently admitted and information contained on the rehabilitation unit file was different to the information held on the office file. The inspector spent time on the unit with care staff and professionals, the team leader told the inspector that she undertakes staff supervisions and risk assessment but had not received training in these areas. Although the care staff and professional had specific roles to play it was unclear who makes the decisions and has overall responsibility for the care provided on this unit. The registered person must ensure that a management structure is put into place, which ensures that the needs of the service users within the home are met. Broadfield House DS0000035758.V254257.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): 7,8,9 and 10 Each service users had an individual care plan, more attention and detail is needed to ensure that service user health care needs are fully met. Service users are cared for in such away that ensures their dignity and privacy. EVIDENCE: Each service user had a care plan and all care staff completed a daily diary sheet, which recorded the care given and any significant events. Care plans were reviewed however not all care plans were dated or signed. It was noted that some service users files held a number of old care plans and it was not clear which was the up to date current plan. The possibility of archiving old care plan and ensuring current care plans are dated and signed was discussed with the registered manager. The files of four service users were viewed in detail as part of the inspection process. On the day of the visit two service users files did not contain information relating to health care needs. Discussion with the management team confirmed that both the service users needs were being met. Risk assessments were in place along side the care plans however these did not provide instruction for staff on what actions were needed to minimise the risk. The home had a medication policy and procedure in place, training for staff was seen on individual staff files and staff were able to confirm they had received the training. The registered manager was advised to undertake Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 11 regular audits on each unit to ensure that correct procedures are being followed by staff. Broadfield House DS0000035758.V254257.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 and 15 The dietary needs of the service users are well catered for with a balanced and varied selection of food available, which ensures service users individual tastes and choices are catered for. EVIDENCE: The food is cooked in the homes kitchen and fresh produce is used each day. All service users said that the food was very good and that they were always offered a choice. Both hot and cold drinks are provided. Although there is a main kitchen which serves the home each of the four units has a small kitchen facility, this ensures that service users have access to drinks when every they wish. One service user said that staff would always make a drink whenever anyone wants one. There was a poster on each unit, which displayed a set programme of activities for the week. Both the manager and staff told the inspector that the carers provide the activities within the care hours and care staff told the inspector that activities would depend on whether or not they had time in their working day. There was no evidence that programme of activities had been developed from service users interest or that particular consideration had been given for the service users suffering from dementia. The inspector noted that the unit which supports the service users with dementia did not provide any memory aids or Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 13 and staff working on that unit were not familiar with any reality orientation work. The registered person must review the programme of activities and provide adequate staffing hours in accordance with the agreement of registration to ensure that the needs of the service users are fully met. Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a complaints procedure, which ensures that all complaints would be acknowledged and investigated. The home had robust procedures in place to safe guard service users from abuse and harm. EVIDENCE: The home had a policy and procedure in place for the Protection of Vulnerable Adults and all new staff are made aware of this information through the home induction procedure. Both the manager and staff spoken too confirmed the correct procedure they would follow to protect service users. The home had not received any complaints. A complaints policy and procedure was in place and is made available to all service users in the service users guide. Service users told the inspector they had no complaints but knew whom they could speak to if they had any concerns. Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home was clean comfortable and homely and provides an environment that is safe and well maintained for service users living there. EVIDENCE: Broadfield house has recently gone through a full refurbishment. All the furniture and fittings are new and are of a high standard. The organisation has a handy person who visits all the homes and undertakes minor repairs and general maintenance. Services users told the inspector that they feel comfortable living in the home and like the new furnishings. One-service users was very pleased with her new bedroom and said that she likes to spend time in her room because it is so nice. The grounds were tidy and suitable for the service users. At the time of the inspection a conservatory was under construction to provide additional living space for the rehabilitation unit, there was no disruption to the home or service users. Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The policy and procedure for the recruitment of staff ensure the protection of service users. Staff at the home are provided with training, however a number of staff are awaiting mandatory training, which will ensure staff are competent in the job they do. Staffing levels in the home do not ensure that service users social needs are met. EVIDENCE: The home had a robust recruitment procedure in place, which ensured the Protection of Vulnerable Adults. A number of personnel were examined as apart of the inspection process all files showed that a thorough recruitment and selection process had taken place and all new staff had undertaken induction training. Staff were provided with mandatory training and other more specialised training such as dementia, which provides them with the knowledge of the service users group they are working with. However on the day a number of new staff were still awaiting moving and handling and food hygiene courses. Staff said that they felt well supported by the manager in the home but felt more training with regards to specific responsibilities were needed. One staff member was responsible for risk assessments and supervision but had not been provided with training and another other staff members spoken to were not familiar with reality orientation work with service users with dementia. A number of staff had completed the NVQ Level 2 qualification and number of Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 17 staff were working towards the qualification. The registered person will need to ensure that 50 of the care staff has an NVQ qualification by 2005. Staffing levels in the home were sufficient for the number of service users living in the home. However the registered manager told the inspector that no hours had been provided for social activities. Staff spoken too said that they felt they had enough staff on duty however that they did not always have time to provide any activities. (See standard 12) Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 18 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): 38 Health and safety policies and procedures were in place which ensures the safety of service users. EVIDENCE: The home has recently gone through a building extension and a refurbishment programme. All certificates with regards to maintenance of equipment was up to date and the home had a good fire risk assessment in place, which meets with the fire safety officer’s approval. The home had an accident reporting system in place and all accidents were appropriately recorded. Mandatory training for staff in the home covers moving and handling and food hygiene. The registered person must ensure that this training is kept up to date. (see standard 30) Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 19 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 2 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? yes 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 OP6OP3 Regulation 14(1) Timescale for action The registered person must 31/01/06 ensure that a full assessment of needs is undertaken for service users admitted to the home or rehabilitation unit, which include any health care needs. The registered person must 31/01/06 ensure that the service users assessments and care plans for service users receiving rehabilitation care clearly documents the intended outcomes and goals to be achieved including any home visits. The registered person must 31/01/05 ensure that all risk assessments provide instruction for care staff on actions required to minimise any identified risks. The registered person must 31/01/05 ensure that staff undertaking risk assessments are provided with appropriate training in this area. The registered person must 31/01/05 ensure that service users social and recreational interests are met. DS0000035758.V254257.R01.S.doc Version 5.0 Page 21 Requirement 2 OP6OP3 14(1) 14(2) 3 OP7 13(4)(c) 4 OP30OP7 18(1)(c) (i) 5 OP12 16 (2)(m)(n) Broadfield House 6 OP27OP12 18(1)(a) 7 OP30 13(5) 18(1)(c) (i) The registered person must 31/01/05 ensure that the staffing levels in the home meet the needs of the service users and are in accordance with agreement of registration with the Commission for Social Care Inspection. The registered person must 31/01/05 ensure that all staff are provided with mandatory training including moving and handling. 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 Refer to Standard OP7 OP7 OP10 Good Practice Recommendations The registered person should ensure that all care plans are dated and signed. The registered person should consider archiving old care plans to ensure that information held on individual service users files is current and up to date. The registered manager was advised to provide a monthly audit on each unit to ensure that correct procedures are being followed by staff with regards to the administration of medication. The registered person will need to ensure that 50 of the care staff have an NVQ qualification by 2005. 4 OP28 Broadfield House DS0000035758.V254257.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW 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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