Inspection on 14/08/08 for Broadhurst Residential Home

This inspection was carried out on 14th August 2008.

CSCI found this care home to be providing an Poor service.

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

Broadhurst Residential Home 01/03/10

Broadhurst Residential Home 09/02/09

Broadhurst Residential Home 15/08/07

Similar services:

Flint House

Hillview Farm

St Vincents

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Broadhurst Residential Home 35 Broadway Sandown Isle Of Wight PO36 9BD Lead Inspector Mark Sims Unannounced Inspection 14th August 2008 11:30 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 Broadhurst Residential Home DS0000070157.V369027.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. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadhurst Residential Home Address 35 Broadway Sandown Isle Of Wight PO36 9BD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered service (if applicable) Type of registration No. of places registered (if applicable) 01983 403686 01983 568705 PKC Holdings Service post vacant Care Home 25 Category(ies) of Dementia (0), Learning disability (0), Mental registration, with number disorder, excluding learning disability or of places dementia (0), Old age, not falling within any other category (0), Physical disability (0) Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) - maximum number of places 8 Learning disability (LD) - maximum number of places 2 Mental disorder, excluding learning disability or dementia (MD maximum number of places 3 Old age, not falling within any other category (OP) 2. Physical disability (PD) - maximum number of places 2 The maximum number of service users to be accommodated is 25. Date of last inspection 15th August 2007 Brief Description of the Service: Broadhurst is a home providing care and accommodation for up to 25 older people, with some capacity for people with illness associated with mental health, learning disability and dementia. The home has been in existence for many years but was registered under the Company PKC Holdings in July 2007. The home is a three storey detached house located on a prominent site along Broadway, a main road through the coastal town of Sandown, about a quarter of a mile from the shops and amenities of the town. All rooms except two are for single occupancy and arranged over three floors, all but one having an en-suite toilet facility. Ten of the rooms include an ensuite shower. There is a passenger lift that affords access to all but two rooms on the upper Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 5 floors. People who have full mobility occupy these two rooms. Part of the home has been extended to provide bedrooms that open onto a well-tended garden area with a raised fishpond and bird aviary. There are well-tended gardens to the front and rear of the property that in previous year were placed first in the Sandown in Bloom competition. Weekly fees range between £369.25 and £452.41. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures services against core National Minimum Standards. The fieldwork visit to the site of the home was conducted over 8.5 hours, where in addition to any paperwork that required reviewing we (the Commission for Social Care Inspection) met service users, staff and management. The inspection process involved pre fieldwork activity, gathering information from a variety of sources, surveys, the Commission’s database and the Annual Quality Assurance Assessment information provided by the service provider/service. The response to the Commissions surveys was poor with no service user or staff surveys returned. What the service does well: What has improved since the last inspection? The service has introduced a new care planning system, as mentioned above. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 7 The service tells us via the AQAA that they have improved their recruitment and selection process by introducing new application and reference request forms and that they have introduced a new induction programme for staff. What they could do better: The home’s ‘statement of purpose’ and ‘service users guide’ documentation requires renewing, as the information contained within the documents is either dated or does not provide people with the information specified within the Care Homes’ Regulations 2001 or National Minimum Standards (NMS). The service needs to develop a system, which ensures all new service users receive a copy of the ‘service users guide’, which presently is not being consistently shared with people. The service must ensure that the staff are appropriately trained in the use of the new care planning system and that more attention is provided to the risk assessment process, which currently is not identifying potential risks to the service users and therefore how these can be managed to reduce the likelihood of harm or injury. The service must ensure that the staff appropriately carry out the instructions of visiting health professionals’ and that were information should be shared with Doctors, Nurses, etc, the staff are completing this process. The service must ensure that were an event occurs, which effects the wellbeing of the service user, this is appropriately documented and stored (Data Protection) and that a report is sent to us (the Commission), in accordance with Regulation 37. The service must take steps to ensure that medication administration records (mar) are accurately maintained at all times and that any gaps or omission in administration are explained by the use of the appropriate code. All controlled medications, should be check on a regular basis, at least monthly and when no longer in use returned to the pharmacist for correct disposal. The premise is generally well maintained throughout, however, whilst in the garden it was noted that the soffits’ were in a poor state of repair and in need of either replacing or remedial works. The service should attempt, when recruiting new staff, to obtain two written references, where a verbal referee is unwilling to confirm their comments/observations in writing, the service should ask the applicant to supply a further reference. The home must introduce a quality auditing system, which allows for the review and improving of services delivered at the home and which provides Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 8 service users and/or their relatives/representatives with an opportunity to comment on the service. The service must review the homes’ process for managing and/or supporting people with their finances, transactions must be doubled signed and receipts both obtained and maintained in an auditable/traceable system. 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. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 9 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 Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 10 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives do not have access to up to date information, needed to choose a home that will meet their needs. EVIDENCE: A review of the information, made available to the people moving into Broadhurst, established that the current hard copy of the ‘statement of purpose’ was in need of updating, as the details of the service and the address of the Commission were incorrect. The Responsible Individual for the Organisation, which operates Broadhurst, was able to demonstrate that changes to the database version of the document had been made, with our new address entered, however, the services’ details remained incorrect. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 11 The ‘service user guide’, should also be reviewed, as in its current format it fails to provide people with the information required and/or recommended within the Care Home’s Regulation 2001 and the NMS. In discussions with the Responsible Individual, it was ascertained that the ‘service users guide’ is not always circulated to people, in accordance with the Regulations. It was advised at the time that the service must establish a system for ensuring this document is made available to all actual and future service users, an issue, which the Responsible Individual and service have committed to addressing. The home does have a brochure, which is available to the service and which can be provided to people on making enquires, etc. This document provides basic information about the home and the services provided at Broadhurst. Pre-admission assessments would normally be undertaken by the services manager or in their absence the deputy manager and recorded on a proforma document. The assessment of the person most recently admitted to the home was reviewed during the visit and found to contain basic information about the person, not to be signed or dated and to provide no indication as to where the assessment took place. However, a discharge summary provided by the Local Hospital (St Mary’s’ Hospital) was also available and between the two documents it was possible to determine the care or support needs of the person and the reasons for their admission to Broadhurst. The service does not provide an ‘Intermediate Care Service’, and therefore a review of Standard 6 is Not Applicable. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 12 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, and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is not based on their individual needs and is not well delivered or documented. The principles of respect, dignity and privacy are however, put into practice. EVIDENCE: The service states via the AQAA that: ‘we have introduced more comprehensive care plans’. During the fieldwork visit it was confirmed that a new care planning system has been introduced. However a review of the plans suggests that the staff have not yet fully familiarised themselves with the new system and whilst they are ensuring the assessment tools and monitoring tools are being used, they are not adequately transferring this information to the care plans or risk assessments. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 13 An example being a resident who has a history of epileptic seizures, who had no plan in place that informed the staff of how the persons’ seizures present or how, should they have a seizure, the staff are to respond. The home’s risk assessment does identify the persons’ epilepsy as a potential cause of harm, as they feel seizures could lead to falls, the staff are directed to observe the person and provide medication. However, this does not consider the affects on the body of the seizure, nor does it consider the need for medical intervention and support post the seizure. Information obtained from the Local Authority, prior to the report being completed indicates, that they also identified serious concerns, which affect the quality of care provided to a service user. This reflects the lack of leadership, with the home presently having no Registered Manager and an acting manager with no senior managerial experience. Staff are also failing to demonstrate, via the running records, that they are supporting service users to access appropriate health care services, or that people’s health and welfare is being appropriately monitored. An entry in the doctors’ or health professionals records indicate that a client had a diuretic (water table) stopped and that the staff were asked to record daily the persons’ blood pressure for one week. On checking the running records however, there are only entries or records for three days and no indication that this information was provided to the requesting doctor, for him/her to request a stop to the tests. Another example involved the doctor visiting a service user and requesting that the optician, scheduled to visit the home in July 2008, see the person during this time, however, the optician visited and the service user was not seen or included on the list of people to be reviewed. The service could also improve its management of accident records with the review of the accident log, establishing that accidents are documented both in the running records and accident book but are not being appropriately reported to us (the Commission), in accordance with Regulation 37 of the Care Home’s Regulations 2001, or being stored according to Health and Safety guidance, which requires accident sheets to be maintained in compliance with the Data Protection Act. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 14 An example being a service user who suffered two falls in the one night, the second resulting in a ‘Gash to the scalp’ and a skin flap injury to their left arm. The service tells us via the AQAA that: ‘we have introduced a locked medication and storage room’. During the review of the home’s medication system it was confirmed that a new medications storage room had been created and that this area provides a safe facility within which to store the service users’ medicines. The home presently operates a monitored dosage system (MDS) produced and supported by a local pharmacist. Staff training records indicate that staff involved in administering medications to the service users have completed medication training courses and that four additional staff are scheduled to complete there training later in the year. However, whilst reviewing the home’s management of people’s medications it was identified that attention is required to record keeping, with unexplained or unspecified gaps appearing in the medication administration records. The review also identified that a controlled medication, which was stored correctly, within a suitable controlled medication cabinet, was not being properly monitored and checked, the controlled drugs register documenting that the medicine was last used or checked on the 13th March 2008 and the fieldwork visit occurring on the 15th August 2008. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities could be improved to better meet individual’s expectations. EVIDENCE: The service tells us via the AQAA that: ‘weekly activities programmes are posted by the dining room’. During the fieldwork visit the activities programme was not observed to be on display outside the dining room, however, copies of forthcoming visits by ‘Independent Arts’ were seen on display in the office. In discussion with service users it was stated that the home’s activities schedule or programme is meeting their needs, people discussing the weekly shopping trip, the bingo sessions, which was more popular with some people than others and the musical entertainment. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 16 The Responsible Individual also discussed the creation of the activities coordinators role, which is designed to ensure that at times when no formal entertainments have been arranged the co-ordinator is available to organise events/activities, the co-ordinator is currently employed to work two days a week. The home’s visiting arrangements are detailed within the ‘service user guide’ / ‘statement of purpose’ literature and whilst the documents may require updating, the information provided around the homes ‘open’ visiting arrangements remain current. During our visit, visitors were observed arriving at the home and being welcomed by the previous manager and care staff before meeting up with their next-of-kin. People are also supported to maintain contact with family and friends, etc, via phone, with one person visited during the fieldwork visit having had a land (telephone) line installed in their room. The mix of lounges and dining areas, available to residents and their relatives, ensures that meetings can be conducted in private, although their single occupancy rooms can be used if they prefer. On entering and leaving the home visitors are invited to date and sign the visitor’s register, which provides both an indication of the people in the home in the event of the need to evacuate and a record of the people visiting the service. The care planning records discussed earlier in the report reflect people’s choice over rising and retiring times, their terms of address and generally their wishes with regards to the delivery of personal care, although this could be more specific and detailed. People spoken with in the small lounge indicated that they choose to use this lounge, rather than the large television lounge, as they can talk to each other much easier, some of the people who use the larger lounge described, as being less able to sustain conversation or participate in a conversation. The tour of the premise allowed us (the Commission) to observe people’s bedrooms’ and to speak with the occupants, who confirmed that the room was decorated, furnished and set out in accordance with their wishes, one person, as stated, having had a telephone line installed. The service states, via their AQAA that: ‘we encourage service users to participate in the choice of menu’. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 17 The tour of the premise enable us to visit the kitchen, dining room and food storage facilities, where time was taken to speak to the catering staff. The member of the catering staff team on duty during the visit was able to confirm that she had completed food hygiene training. She also discussed the menus and showed us the records maintained in respect of the food served and the equipment checks undertaken. The food storage facilities were appropriate and provided sufficient dry, cold and frozen food storage and there was a range of catering and/food items available. Observations made during lunchtime, established that mealtimes are social occasions and that sufficient staff are around to support the service users eat their meals. During conversations service users confirmed that they prefer a smaller meal in the evening, sandwiches, cheese-on-toast, etc, as the main meals are sufficiently large. People also stated that the menus provided a variety or choice of traditional British foods, which, they felt, were appreciated by the current service user group. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service are not being enabled to express their concerns and do not have access to an either an effective complaints procedure or a system that protects them from abuse or harm. EVIDENCE: The service tells us via their AQAA that: ‘we thoroughly investigate and document any complaints. Ensure that service users and their families are aware of the complaints policies and procedures’. A review of the home’s complaints logging system, establishes that the complaint, the outcome of the home’s investigation and the action undertaken to remedy the concern/complaint are documented, as stated via the AQAA. However, it is unclear how the home makes service users and their relatives aware of the homes’ complaints process, as the ‘statement of purpose’ contains out of date information relevant to the making of a complaint, services’ details and the address or contact details of the Commission. The Responsible Individual confirmed that the service has no system for ensuring that the ‘service users guide’ is circulated to residents’ or their relatives. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 19 The home’s complaints procedure was also not seen on display around the building during the tour of the premise. The dataset, which forms part of the AQAA documentation, does establish the existence of the home’s complaints and concerns procedure and that this was last reviewed in the January of 2008. The dataset also contains information about the home’s complaints activity over the last twelve months: No of complaints: 2. No of complaints upheld 2. Percentage of complaints responded to within 28 days: 100 . No of complaints pending an outcome: 0. The evidence suggesting that despite people not being made aware of the complaints process people’s complaints are being appropriately handled and resolved. The homes tells us, via their AQAA and dataset, that policies on the protection of service users are in place, ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’, both policies updated in the January of 2008. The dataset also establishes that over the last twelve months no safeguarding referrals have been made to the Local Authority, however, our (the Commissions) records indicate that a ‘safeguarding’ concern was raised following an accident, which resulted in the death of a service user. The Coroner whose findings are a matter of public record reviewed this incident the incident is now closed. We have also received two notifications relating to safeguarding issues, since the AQAA was completed and returned. Both reports are presently being investigated by the Local Authority Social Services Department, who have raised concerns with regards to the services risk assessment process and the identification and delivery of care in accordance with people’s needs and wishes. One such concern has resulted in a person allegedly being left without due care and attention in conditions that were not acceptable, and did not protect the persons health and well-being. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 20 The staff records indicate that care staff are being provided with access to ‘safeguarding training’, however, this is in small groups, which does not appear to ensure that all staff are up to date with this aspect of their training. Given the home’s recent experiences and its history of poorly managing risks, it was felt more attention should have been given to the home’s risk assessments. The service failing to clearly identify areas of potential risk to people and thus failing to produce plans that either adequately manage the risk or attempt to reduce the potential for harm to the service user. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 21 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour of the premise was undertaken in the company of a director. The tour established that the home is in a reasonable state of repair internally and reasonably well decorated throughout, the director indicating that during the winter the corridor leading to the extension is to be redecorated. The communal areas or facilities are well set out, with the choice of lounge providing a variety of environment for the service users, whilst the bathrooms and toilets are easily accessible from the communal areas. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 22 All of the bedrooms, seen during the tour provided en-suite facilities, many including a shower, as well as a hand-basin and toilet. It was also established or observed that the rooms visited contained items of an individual nature, pictures, ornaments, pieces of furniture, etc, which had been used by the occupant to personalise their room. Externally the gardens are well kempt and offer a sheltered area for the service users, with the additional attractions of an Avery and well-stocked pond. During the tour of the gardens it was observed that the soffets are in a poor state of repair, which was brought to the attention of the director, who acknowledged their condition and stated that presently consideration was being given to either repairing the damaged areas or replacing the soffets, although a decision had at the time not been reached. It was advised that this issue would require attention before the next inspection visit. The home employs a maintenance person, who during the fieldwork visit was observed around the home and who has a workshop attached to the premises. In conversation with the Responsible Individual it was explained that when care staff identify or discover a maintenance issue, they should document it in the maintenance log, which is left in the office, this document was seen. The maintenance person is then required, on a daily basis, to review the jobs recorded and address them in order of importance, ensuring any thing that is likely to affect the service users is addressed as quickly as possible. Once the job has been completed the maintenance person is required to sign the job off in the book. The service tells us via the AQAA that: ‘more domestic staff have been employed’. Domestic staff were observed during the visit undertaking their duties. The home was noted to be free from odours and clean and tidy throughout. The AQAA also tells us that staff receive access to training on the management and control of infections and that policies and procedures are available, these were last reviewed and updated in the January of 2008. Communal toilets and bathrooms were noted to contain liquid soaps; paper towels and bins for the disposal of waste and all chemicals were stored in accordance with the ‘Control Of Substances Hazardous to Health’ (COSHH) regulations. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 23 The laundry is not located within the main building but is accessible to the staff at the end of the extension. Laundry is the responsibility of the care staff that launder service users clothes and return them to the persons’ room. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 24 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and provided in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The Responsible Individual stated during the fieldwork visit that she is responsible for producing the duty rosters for the home and that she attempts to maintain a rolling roster, which only alters if people are on leave or absent through sickness. A copy of the home’s duty roster was seen during the fieldwork visit and indicated that sufficient care and domestic staff are on duty to meet the needs of the service and the service users’. The roster establishing that each morning shift is covered by three care staff, plus a domestic staff, cook, maintenance operative and member of the management team. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 25 The afternoon shifts are also covered by three care staff, however no ancillary staff are present and therefore issues or tasks like cooking teatime meals, etc, are completed by the care staff. Observations made throughout the day support the fact that sufficient staff were employed at the home and that the needs of the service users were being met, with care staff, domestic, maintenance and catering staff all seen around the home during the fieldwork visit. During a conversation with the Responsible Individual it was ascertained that the role of training co-ordinator has been delegated to the deputy manager. Training records are available, however, there is no training plan or schedule and the service does not use a matrix system, etc, to record or track training sessions completed or when update sessions are required. The training records identify that the staff are completing courses of both a mandatory nature, food hygiene, fire safety, moving and handling and skills development courses, diabetes awareness, abuse awareness and dementia awareness. Copies of the certificates awarded for the completion or attendance of a training event are also maintained on the staff’s personnel files. We were provided with sight of the home’s induction programmes and associated documentation, the in-house induction is used to familiarise the new employee with the environment and where information can be accessed, the ‘Skills For Care’ (SFC) common induction standards are available to assist new staff develop knowledge and awareness of the basic skills required when caring for people. Information taken from the dataset indicates that currently the home employs twenty-two care staff. During the visit it was established that eight of the twenty-two care staff have completed a National Vocational Qualification (NVQ) at level 2 or above and this gives the home a percentage of 36 of its care staff possessing an NVQ at level 2 or above. Two additional care staff are completing their NVQ, which would increase the percentage of staff holding an NVQ level 2 or equivalent to 45 should their be no changes in the staff team in the meantime. This information conflicts with the data provided via the dataset, which indicates that only six staff possess an NVQ at level 2 or above and that a further six are completing the training, this would equate to 54 of the staff team achieving an NVQ at level 2 or above. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 26 Information contained within the dataset also establishes that a recruitment and selection strategy/procedure exists to support the management staff when employing new staff. It indicates that all of the people commencing work within the home over the last twelve months have undergone satisfactory pre-employment checks. On reviewing the files of the two most recently recruited staff most of the required checks were in place, Criminal Records Bureau (CRB) checks, Protection Of Vulnerable Adults (POVA) checks and two references, although on both files one of the reference was verbal and the regulations require two written references. In discussion with the Responsible Individual the need to obtain written verification of the verbal reference was discussed. The previous manager stated that she sent out a reference request form with a self-addressed and stamped envelope, however, people are reluctant to return written references. The service has been reminded that it is the applicants job to ensure two written references can be provided and that if a verbal referee is unwilling to return a reference request consideration to approaching a third party/person should be given. The files also contained completed application forms, health declarations, photographs of the employee, personal information and information used to support the CRB application process. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 27 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, 33, 35 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a Registered Manager and there is no effective quality assurance system in place, which ensures the welfare and wellbeing of the service users is being promoted. Service users financial records are not being correctly managed and the disorganised record keeping does not ensure people’s financial interests are promoted. EVIDENCE: The service state via the AQAA that they manage and administer the home by ensuring: ‘Qualified manager being continually updated’. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 28 ‘Auditing Care’. ‘Regular updating of mandatory training’. ‘Referrals to Court of Protection for residents unable to control their own monies’. ‘Updating policies and Procedures’. A review of our (the Commissions’) database establishes that the service has been without a Registered Manager for over eighteen months. It is imperative that the Organisation recruit a person suitable to be considered for the role of the Registered Manager. The need to employ a competent and capable manager, who can be put forward for Registration with us (the Commission), is reinforced by the fact that the home needs to focus on addressing the following areas identified within the body of the report: ‘Updating of the ‘statement of purpose’ and ‘service users guide’. ‘Improved use of the new care plans and risk assessments, especially given the homes’ recent experience’. ‘Appropriate monitoring of people’s health and welfare and adherence to requests, from professionals for people’s health to be monitored, etc. ‘Improved monitoring of the medication system’. ‘Improve the home’s reporting under Regulation 37 and ensure accident forms are properly stored’. ‘Attention to the external aspects of the property’. ‘Obtaining of two written reference for new employees’. ‘Service to submit and application in respect of the Registered Managers’ position’. ‘Improved/increased quality auditing/assurance’. ‘Improved record management when handling people’s finances’: and the issues identified by the Local Authority via the Safeguarding investigations. The Responsible Individual wrote to us shortly after the Inspection visit to inform us that the proposed manager had resigned and would not therefore be submitting an application in support of the Registered Managers post. As a result of information shared with us by the Local Authority, as referred to earlier in this report, we have become seriously concerned about the leadership of the home and the inability of the service to effectively discharge its responsibilities to the people living at the home. The service states, via the AQAA, under the title ‘What We Could Do Better’: ‘More in-depth auditing of our services’. The home’s present quality auditing system is poor, with no formal processes available, which would enable the service users or their relatives / Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 29 representatives to become involved in the reviewing of the services provided at the home. Care plans and risk assessment documents are being reviewed and updated in accordance with the recommendations of the National Minimum Standards (NMS), although the content of the documents, as stated earlier in the report require expansion, as presently they do not effectively identify or set out the needs of the service users. Information taken from the ‘Dataset’ suggests that the home’s policies and procedure documents were reviewed and updated in January 2008, however, neither the ‘statement of purpose’ nor the ‘service users guide’, were found to be accurate or up to date. The previous manager, who was to be proposed for Registration by the Organisation; and her team also seem to have had no formal means or methods of monitoring the practice / performance of the staff, with the gaps in the medication records not detected and the controlled medications not audited on a regular basis. The previous manager did state that she was undertaking ‘appraisals’ for staff, however, she had no formal process for scheduling when the, appraisals, were to take place, as the diary system she said she used was found to lack organisation. An example being the previous manager’s statement that she was due to undertake the deputy managers’ supervision during the week of the fieldwork visit but this did not appear in the diary. The management of service users monies was also found to lack an auditing system that ensured people’s financial interests were being safeguarded, the receipts obtained in support of purchases not maintained in an auditable or traceable way and transactions not double signed. Regular checks on the balance of the accounts were being undertaken and when checked all accounts were accurate. Monies held or stored on behalf of the service users was being correctly and safely stored and all accounts were maintained on an individual basis. The dataset establishes that policies and procedures are available to support the management and/or staff manage clients’ valuables and monies and that these were last updated in January 2008. The service tells us, via the AQAA and Dataset that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 30 Health and safety training is being made available to staff, with the training records providing evidence of the courses attended, including: health and safety, food hygiene and moving and handling. The tour of the premise identified no immediate health and safety issues and the maintenance person is available to address urgent issues as they arise. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 31 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 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 2 X 2 X 2 X X 3 Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 32 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 OP1 Regulation Requirement Timescale for action 30/10/08 2. OP1 3. OP7 4. OP8 5. OP9 6. OP16 Regulation The service must ensure that an 4 accurate and up to date ‘statement of purpose’ is made available at all times. Regulation The manage must ensure that a 5 ‘service users guide’, which addresses all aspects of Regulation 5 and National Minimum Standard 1 is made available to all service users. Regulation The service must ensure that 15 plans of care are produced, which identify how the service users needs, in respect of their health and welfare is to be met. Regulation The service must take steps to 12 ensure that the staff are monitoring the health and welfare of service users, as directed by professional health and medical personnel. Regulation The service must make 13 arrangements for the safe handling, storage and recording of service users medicines received into the home. Regulation Details of the home’s complaints 22 process must be made available to service users and/or their DS0000070157.V369027.R01.S.doc 30/10/08 30/09/08 30/09/08 30/09/08 30/10/08 Broadhurst Residential Home Version 5.2 Page 33 7. OP18 8. 9. OP29 OP31 10. OP33 representatives/visitors. Regulation The service must ensure that 13 risk assessments are appropriately completed and any unnecessary risks to the health or safety of the service users identified and so far as possible reduced/managed. Regulation The service must ensure that all 19 employees have two written references. Regulation The Provider Organisation must 8. take steps to ensure an application, in respect of the Registered Service’s position is submitted to the Commission for Social Care Inspection. Regulation The service must establish and 24. maintain an effective quality assurance and monitoring systems, which seeks the views of the people who use the service. This requirement was raised at the last inspection 30/09/08 30/09/08 30/09/08 30/10/08 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. Refer to Standard OP1 OP35 Good Practice Recommendations The service should develop a system that ensures all actual and prospective service users have access to a copy of the ‘service users guide’ The service should ensure that the system for managing and auditing service users monies is safe and transparent/auditable. Accounts should be double signed and individual receipts provided for all transactions. Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 34 Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Broadhurst Residential Home DS0000070157.V369027.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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