Inspection on 09/02/09 for Broadhurst Residential Home

This inspection was carried out on 9th February 2009.

CSCI found this care home to be providing an Adequate 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 14/08/08

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 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Broadhurst Residential Home 35 Broadway Sandown Isle Of Wight PO36 9BD Lead Inspector Anita Tengnah/ Mick Gough Unannounced Inspection 10:00 9 February 2009 th 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.V373932.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.V373932.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 manager (if applicable) Type of registration No. of places registered (if applicable) 01983 403686 01983 568705 funfactfantasy@aol.com PKC Care Ltd Manager 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.V373932.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: Old age, not falling within any other category (OP) Dementia (DE) - maximum number of places 8 Learning disability (LD) - maximum number of places 2 Physical disability (PD) - maximum number of places 2 Mental disorder, excluding learning disability or dementia (M)D maximum number of places 3. The maximum number of service users to be accommodated is 25. 2. Date of last inspection 14th August 2008 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 condition of registration denotes the maximum number that can be accommodated in each category. The home 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. There is a passenger lift that allows access to all but two rooms on the upper floors. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 5 Broadhurst Residential Home DS0000070157.V373932.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 1 star. This means the people who use this service experience Adequate quality outcomes. An unannounced visit to the service was undertaken as part of the inspection on the 9th February 2009. The process included a tour of the service where a number of the bedrooms, communal areas, laundry and bathrooms were viewed. As part of case tracking staff and service users views were sought, care, staff and other records were looked at. We sent out our Annual Quality Assurance Assessment to the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This is included in this report, as was information gathered by the Commission since the last inspection to contribute in assessing judgements in this report. We also undertook a Random visit to the service on the 5th of February 2009 to follow up on a Statutory Requirement Notice and reference to this will be reflected in the body of the report as appropriate. What the service does well: What has improved since the last inspection? The system of care planning and risk assessments has been introduced. The manager has looked at medication management and putting in new procedures in place fro the safe management of medicines at the service. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 7 A manager has been appointed who has day- to- day management responsibility for the service. What they could do better: The registered person must ensure that an up to date statement of purpose and service users’ guide are developed and available to the service users. Information must be current and the service users’ guide available to the service users. The care plans and risks assessments must reflect the current needs of the service users. Detailed information must be available in the care plans on how the assessed needs of the service users would be met. Staff must ensure that accurate records of care given are maintained to protect the service users. The registered person must ensure that staff follow guidance for the medication management and accurate records are maintained including any changes to the service users’ prescriptions. A record of all safeguarding referrals and actions taken must be maintained in order to protect the service users. The current laundry arrangements/ facility is inadequate and does not protect the health and safety of people accommodated. The registered person must put in place a programme for the fitting of appropriate door locks to the service users’ bedrooms. As part of the refurbishment programme, the registered person must ensure that the furnishings are included in particular the dining room furniture, so that people are provided with good standard of furnishing to meet their needs. The registered person must ensure that there is adequate staff at all times to meet the needs of the service users. A review of the excessive hours worked by some staff must be completed. The registered person must ensure that care hours are not eroded by noncare duties. So that it is ensured that people’s care needs are met. The responsible person must undertake monthly reviews of the care and service provided as required by Regulation. Records of these visits must be available at the service. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 8 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.V373932.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.V373932.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has put in place a process to ensure that the service users’ needs are assessed prior to care being provided. The statement of purpose and service user’s guide are not currently accurate to reflect all the information required. There has been no new admission to the service, it is not possible to assess if the home’s polices and procedures are reflected in practice in terms of supporting people to make a decision about moving into the service. EVIDENCE: We looked at the information available to prospective service users in order to help them make an informed choice prior to moving into the service. The provider reported that since our last visit in November 08 they had developed Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 11 their statement of purpose. A copy of the document was available in the entrance hall. The document has been developed, however it did not contain all the information as required. We brought this to the attention of the registered person, as this must include information such as the age, range and sex of the service users for whom it is intended to accommodate. Other information must include the criteria for admission and including the home’s policy and procedures for emergency admission. Other information must include the arrangements for the reviews of the service users’ plan and the complaint’s procedure. The last inspection report had required that a service users’ guide is developed and accessible to the service users. We spoke to the provider who stated that the service users’ guide had not yet been developed and would be working on this. The provider must ensure that this document is available as part of the information provided to the service users. The manager reported that the pre admission procedures have been reviewed. The provider confirmed that there has been no new admission to the service since our visit in November 08. This followed a voluntary agreement that no new service users would be admitted in the interim period. We have not therefore assessed the pre- admission outcome area at the time of this visit. The manager confirmed to us that the home service does not provide intermediate care. Broadhurst Residential Home DS0000070157.V373932.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are some care plans and assessments in place. However further development is required to ensure that all risks areas have been assessed to ensure that all needs are met safely. Access to the local healthcare team is available. The service is supported by external agencies in meeting people’s healthcare needs. The medication management has been developed. Details of any changes in prescription were inadequate, as these were not recorded, which may put people at risk of not receiving their medication safely. The service users say that they are treated with respect. EVIDENCE: We looked at the records of four service users at the time of the Random visit on the 5th of February 09 and two records on the 9th of February 09. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 13 We noted that a new assessment format and care plans had been introduced since our visit. We found that the care plans now contain moving and handling assessments and falls risk assessments. The assessments and care plans contained some information, however these did not accurately reflect the current needs of the service users. There was some evidence that the care records had included skin integrity assessments such as Waterlow score. These were not updated in all the care records that we looked at. One of the records showed that this was last updated in July 08. The daily records of care were inadequate and did not show what care have been administered. One of the records showed that the service user’s needs had been met in relation to numbered care plans. This was inaccurate as the assessments and care plans were blank that would denote the care required. This fails to be meaningful in delivering care to support people’s needs. You have confirmed to us that the disability team was assisting the staff in developing person centred care plans for those service users and this would be put in place. This was not in place at the time of the visit and meant that full person centred planning did not support the meeting of people’s needs with a learning disability. There was a lack of assessments in relation to nutritional needs and incontinence at the time of the visit for people who had needs in terms of these areas of care and support. The risk assessment and care records for one of the service users showed that they were on a pureed diet. We observed that this person had been given a normal diet on the day of the visit. The care records contained conflicting information about this person’s dietary needs, which could put them at risk of not receiving the diet that they require. Although the home had introduced a dietary assessment format, this was not completed in all the records that we looked at. Information relating to the continence management of the service users was also conflicting and did not accurately reflect the needs of the service users. There was no continence assessment in the records that we looked at. Another service user’s care plan contained risk assessments, however there was conflicting information contained in the risk assessment. It stated that blood pressure should be recorded daily, when in fact this was not the case as the GP’s notes clearly showed that the monitoring was changed to monthly. This could be confusing for the staff and the risk assessment should reflect the current needs are identified and met. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 14 You must ensure that assessments are completed as required and action plan put in place to demonstrate how the assessed needs of the service users will be met. The manager reported that all the service users are supported to access healthcare as required. The provider reported that the local Primary Care Trust and the disability team have been working with the staff in reviewing care plans and assessments for the service users and work in these areas are ongoing at present. As part of care planning and reviews, there was no evidence of how this information was gathered such as involvement of the service users/ relatives. This is particularly relevant for those service users who are not able to participate in their care planning due to their frailty. We looked at the process that the home has introduced for the safe management of medication that the home undertook on behalf of the service users. We found that medication was stored securely and this included creams and ointments that have been prescribed. A random sample of the service users’ bedrooms and the communal areas indicated that these were not left in communal areas. Cream found in one of the bedrooms we visited belonged to the named service user. A random sample of the Medication Administration Record (MAR) sheets indicated that staff were recording oral and some topical medication administered. However this was lacking for prescribed ointments/ creams and must be recorded as required. The care record for one of the service users showed that they had a sore groin and cream was to be applied. There was no record of this on the MAR chart and the daily record did not include this information. We found that one of the service user’s had been prescribed a Nebuliser to be given four times a day and she had received this five times on different occasions. There was no record to show on whose authority the increased dosage was being administered. This showed that the service user was receiving medication contrary to their prescription, which may compromise their wellbeing. One of the service users record showed that a risk assessment had been completed in order to manage some of her own medication and there was a risk assessment in place for this and this was agreed by her GP, we spoke to the home’s manager who told us that the home was looking to provide more support to enable her to manager all of her own medication. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 15 The provider reported to us that they were in the process of changing pharmacy supplier and this would include staff training. Staff also confirmed that the home would be receiving a new controlled drug cupboard that complies with the Misuse of Drugs (Safe Custody) Regulations 1973. The Commission served the provider with a Statutory Requirement Notice in January 2009 in relation to care planning and medication management. We visited the service to monitor this notice and to see that the provider has taken action regarding the above. We found that some action has been taken to meet the requirement. However this is not currently fully implemented and sustained in practice. We spoke to eight service users and observed the staff interaction as part of the visits. The people we spoke to tell us that they were offered choice in the activity of daily living. There was information in the care plan that one of the service users did not like to eat breakfast but would have a cup of tea in their room at 8am.When we spoke to them they confirmed that staff complied with their wishes. This person said that they were free to make their own choices and said that they did not like to take part in any of the organised activities but preferred to go out on their own. Comments from residents included “I have lived here 11 years and I am quite content” another said “I couldn’t be happier, they treat me very well and if I need anything all I have to do is ask” Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a planned programme of activities that was being further developed at the time of the visit, so that people benefit from a greater range of opportunities to meet their diverse needs. The meals offered at the home met with the satisfaction of the service users and choices were available. EVIDENCE: The provider reported that there is a planned programme of activities for the service users. A list of the activities was displayed on the notice board at the service that included armchair exercise, bingo, shopping trips, arts and crafts and musical interludes. Residents spoken to say that they enjoyed activities at the home. One resident particularly enjoyed the arts and crafts and we observed her making cards in the dining room. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 17 The manager reported that as part of developing the key worker system, the carers would be involved in providing activities for the service users. The home was starting to record the service users’ life history and further develop this to ensure that these are reflected in the service users’ care plans. The records of activities in the care records that we looked at did not reflect what activities had been undertaken. It was not therefore possible to monitor and identify people’s ongoing social needs The home supports the service users in maintaining links with the community. One of the service users attends a Sunday and Friday club that she said she liked very much. The vicar visited the home on the first Wednesday of the month and two of the service users are supported to attend church on Sundays. The home operates an open visiting policy and maintained records of visitors to the service. The home has in place a planned menu, which is changed regularly and the chef reported that residents’ likes and dislikes are taken into consideration. Residents told us that the cook comes round each day and tells them what the menu for the day is and if this is not to their liking then he provides alternative choices. A record of food eaten by residents is kept and currently no residents require pureed meals, however the cook was aware of the need to puree food individually if required to provide colour and textures that could be enjoyed. We observed the lunchtime meal and this indicated that the service users were provided with alternative to the main meal. The cook told us that there is always a choice of desserts that we noted was available at the time. The evening meal is a hot snack type meal and residents are able to have drinks throughout the day and night and staff are able to make snacks for residents at any time. All of the residents that we spoke with told us that the food was good and that the cook walked around the home regularly. One resident told us “the cook knows what I like and he will always make something different if I want it.” We observed lunch being taken in the dining room and meals were well presented and staff provided appropriate support. During the last random inspection two people said that they didn’t like the cottage pie, but had not been offered anything else. Comments from other service users were that they were offered hot drinks at bedtime and were not aware that snacks were available. The process of how choices relating to bedtime snacks need to be looked into to ensure that the service users are aware of this. Care records in relation to dietary needs should be developed to reflect this. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 18 Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a satisfactory procedure in place to deal with concerns and complaints raised. Safeguarding procedures for the reporting recording and action plans in relation to the protection of people living in the home need to be further developed, as these were inadequate. EVIDENCE: We looked at the complaint procedure and the way that the provider dealt with any concerns/ complaints that are raised. A complaint procedure was available and this was displayed in the entrance hall. The service user we spoke to were not aware of the procedure but said that they would tell the staff if they were unhappy. The service maintains a complaint log of complaints/ concerns that they received. The complaint log that we looked at indicated that the home had dealt appropriately with the concerns raised and recorded them as required. There have been two safeguarding alerts that had been raised since the last visit. We received information regarding an alert that the home did not report to social services as per the procedure and undertook their own investigation. Following the last visit in November 08 we made a referral to the safeguarding team as we had concerns relating to the welfare and well being for two of Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 20 users accommodated. This has been investigated and we have not yet received the outcome of this investigation. During the visit on the 9th February 09 we noted that there was a record of a service user who had reported they had lost some money. This had not been referred as safeguarding as the responsible individual stated that the service user had said they did not want the police involved. The home must have clear procedures in place to ensure that any allegation is reported to the appropriate authority in order to safeguard people living at the home. The responsible individual must ensure that procedures are in place for the reporting, recording and any action taken following completion of all safeguarding referrals. There was no information/ record of the recent safeguarding referral and investigation as required. The staff that we spoke to were aware of what constituted abuse and said that they would report to the manager or social services. The provider stated that some of the senior staff have completed training in safeguarding following the previous safeguarding recommendation. Further training in safeguarding and mental capacity was being developed at the time of this visit for all the staff. The responsible individual must ensure that the recent guidance on safeguarding is accessed and put in place and staff updated with its contents. Broadhurst Residential Home DS0000070157.V373932.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was clean and homely in most parts. Further renovations of fabrics and cleaning procedures need to be developed. The laundry facility is inadequate and does not protect the service users. EVIDENCE: We walked around the service as part of the two visits and looked at some of the service users’ bedrooms, the kitchen, communal lounges, dining rooms and bathrooms. We looked at six of the service users’ bedrooms and found that they were personalised with personal belongings that they had brought in on admission. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 22 The home was clean and mainly in satisfactory state of repair. The provider reported that there is an ongoing programme of refurbishment in place. The last inspection report required that the provider looked at the management of toiletries and creams at the service. During the visits we observed that this has been addressed, no communal toiletries and creams were found in the communal bathrooms. We noticed that one of the service user’s bedroom carpets had a brown stain; this was brought to the attention of the staff. It was reported that this was due to the service user accessing the commode on their own. The company representative stated that the carpets are cleaned regularly, however records of these were not available. We observed that the dining rooms chairs were in poor state and heavily stained. This was brought to the attention of the representative of the company who reported that he had been looking at appropriate covers for the chairs. The manager reported that procedures and information for the prevention of the spread of infection was available. We looked at the laundry facility that the home had in place. The home has a small room where a domestic washing machine was in use. The staff are provided with appropriate red bags that are dispersible for the management of soiled laundry. However the manager reported that staff removed the soiled laundry from the red bags as the washing machine was not equipped to take the bags. There were no procedures in place to demonstrate how the infection control risks would be managed. During the visit we found that the area that was used for the laundry facility was not fit for purpose. This was discussed with the company representative and an appropriate area must be developed to ensure that the laundry meets with current infection control guidelines. Risk assessments for the staff should be put in place in the interim period while an appropriate the laundry room is put in place. The company representative has confirmed that this issue would be looked into and appropriate action taken. We noted that the bedrooms doors did not have any suitable locks to ensure the home respects the privacy and dignity of people using the service. As part of the refurbishment programme this must be put in place and action plan sent to the commission. These should be carried out with a risk assessment framework ensuring that the locks are appropriate to the needs of the service users. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing numbers do not fully protect people using the service, such as excess hours worked by some staff. There is an ongoing training programme in place to support the staff in their roles. Recruitment procedures were satisfactory except for checks on references that were inadequate and did not promote safe recruitment practice, to ensure that people are fit to work with the vulnerable people living in the service. . EVIDENCE: We looked at a copy of the duty roster as maintained at the home. On the day of the visits the manager stated that the home has three carers on the day shifts and two awake carers on night duty. According to the roster this indicated that some of the staff were on duty for up to fourteen hours on night duty. We noted that one carer following a night duty shift came back to work the next day on an evening shift. The roster did not show what arrangements were put in place when the chef was off sick to take care of food preparation. The staff reported that the chef finished work at 2pm and the carers were responsible for the service users Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 24 teatime meals and suppers. The carers also undertook the service users’ laundry. The home has one staff who worked from 9-1pm that provided domestic support for five days a week and two staff on two days a week. The provider must ensure that the home has adequately trained staff and in sufficient numbers to meet the needs of the service users. This is to ensure that care hours are not eroded by non- care duties including cooking and laundry. A review of the excessive hours worked by some staff must be undertaken to ensure that care is provided safely. We looked at two recently recruited staff as part of this visit. Records showed that they had completed an application form and checks such as Criminal Record Bureau (CRB) and POVA first were completed prior to employment. The provider also sought references as part of the checks. We found that for one of them this was appropriate, however for the other carer who had brought in a reference from the last employer and the provider did not carry their own check. The manager reported that there is a training programme in place. Recent training included safeguarding adults training that five staff completed and also the responsible person and the manager. The training programme is being further developed to ensure that staff have the skills in order to provide care safely. Update in medication management is planned for all staff dealing with the service users medication as part of the changes the home is introducing. Information we have received indicated that six staff have completed National Vocational Qualification (NVQ) 3, two NVQ at level 2 and seven staff were undertaking this qualification. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has recruited a manager who needs to complete the fit person process and register with the Commission. The home has been without a registered manager for two years who is skilled and fit to manage the service. There has been recent introduction of internal audit, however this is not currently sufficiently detailed to ensure that people’s views are being reflected in outcomes for people living in the home and will need further development in order to meet regulation. Risk assessments, infection control processes are not fully implemented to ensure that care is provided safely. EVIDENCE: Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 26 The home has recently appointed a manager for the service. The manager has started the process of processing her Criminal Record Bureau (CRB) check and would need to apply to register with the Commission. The registered person was required to establish and maintain an effective quality assurance and monitoring systems, which seeks the views of the people who use the service. The responsible individual reported that a service users’ meeting was undertaken on the 14th of November 08 where some of the relatives attended. Positive comments were received and areas that need action taken were discussed. During this visit we the provider reported that another service users’ meeting was planned for that afternoon. The manager stated that some service users’ questionnaires had been developed and these would be implemented soon as part of the audit. The responsible individual was required to undertake monthly- unannounced visits to the service to monitor how the home is meeting its commitments as stated in the statement of purpose. The responsible individual reported that this had not been completed and action must be taken in order to comply with regulation. The home was not managing any of the service users’ money. The manager reported that they looked after some of the service users’ personal allowance. We saw the file, which provided a clear record of any money paid in and a clear record is kept of all transactions and this provides a clear audit trail. Money is kept in individual envelopes in the safe in the office and we checked the balance for two residents and these were accurate and up to date. The service users spoken with said that they were happy with the current arrangement and had agreed for the home to hold small amount of their personal allowance. The environmental health officer (EHO) visited the service in December 2008 and made some recommendations. The provider stated that EHO had been undertaken further visits to monitor compliance. There was no record to inform the outcome of the visits. We looked at risk assessments including fire risk assessment and servicing records for equipments. There is an in date fire risk assessment for the building and the provider stated that regular health and safety monitoring takes place. The fire logbook was inspected and all appropriate testing and checks have been recorded. There was an in date certificate for the homes Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 27 fire alarm system and for the testing of private electrical equipment and the homes fixed electrical wiring. There was evidence that an approved CORGI engineer had checked the gas appliances in October 2008, however the home did not have a gas safety certificate. Also the home did not have a certificate for the testing of the homes shaft lift, although there was evidence of a service contract for the lift. These were brought to the attention of the provider and must be put in place. The infection control procedures in relation to the laundry arrangements as stated in other section of this report do not protect the service users. Further developments of risk assessments are required to ensure that all risks are assessed and action plan put in place to meet the service users needs safely. Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 28 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 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 2 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 29 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 4(1) (2) Requirement The registered person must ensure that an up to date statement of purpose and service users’ guide are developed and available to the service users. The registered person must ensure that risk assessments are appropriately completed and any unnecessary risks to the health or safety of the service users identified and so far as possible eliminated. The registered person must ensure that the service users care plans reflect their assessed needs and how these are to be met. Accurate records of care given must be maintained as part of meeting the service users’ needs. The registered person must ensure that staff follow procedures for the safe handling, safe administration, recording and disposal of all medicines DS0000070157.V373932.R01.S.doc Timescale for action 25/03/09 2. OP7 13(4) 25/03/09 3. OP7 15(1) 25/03/09 4 OP9 13(2) 25/03/09 Broadhurst Residential Home Version 5.2 Page 30 5 OP18 6 OP24 7 OP26 8 OP27 9 OP31 received into the care home. The registered person must ensure that all safeguarding referrals and action taken are clearly recorded to safeguard people using the service. 12(4) The registered person must ensure that the service users bedrooms are fitted with appropriate locks. The home is conducted in a manner that respects the privacy and dignity of the service users. 13(3) The registered person must 16(2) ensure that arrangement for the laundry facility is appropriate and meet with infection control legislation. 18(1) The registered person must ensure that at all times suitably qualified staff are working at the home and in such numbers as appropriate to health and safety of people accommodated. Regulation The registered person must 8. ensure an application, in respect of the manager is submitted to the Commission for Social Care Inspection. 17(1) (a) Schedule 3. Regulation The registered person must 26 ensure that as part of their internal audit, monthlyunannounced visits are carried out and records of these are available at the service. 25/03/09 30/05/09 30/04/09 25/03/09 30/03/09 10 OP33 25/03/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 31 Broadhurst Residential Home DS0000070157.V373932.R01.S.doc Version 5.2 Page 32 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. 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