Inspection on 26/10/07 for Broadland House

This inspection was carried out on 26th October 2007.

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

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

Other inspections for this house

Broadland House 17/01/07

Broadland House 09/11/05

Broadland House 12/04/05

Broadland House 19/10/04

Broadland House 18/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Broadland House Bridge Road Potter Heigham Great Yarmouth Norfolk NR29 5JB Lead Inspector Maggie Prettyman Unannounced Inspection 26th October 2007 09:15 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 Broadland House DS0000059149.V353755.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. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadland House Address Bridge Road Potter Heigham Great Yarmouth Norfolk NR29 5JB 01692 670632 01692 670632 susan.hollyman@virgin.net 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) Mrs Susan Hollyman Mr Raymond Hollyman Manager not registered Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty (20) Older People who may have Dementia may be accommodated. Total number not to exceed 20. 17th January 2007 Date of last inspection Brief Description of the Service: Broadland House is a care home providing personal care and accommodation to 20 older people who may also have dementia. The home is privately owned. The owners are experienced providers having two other homes in the area. Broadland House is located in Potter Heigham and is within walking distance of shops and other facilities. The service has 16 single bedrooms and 2 double rooms. Eight of the single rooms have en-suite toilets. The home informed CSCI of its charges in October 2007 and charges from £333 - £367 per week for care provision. Residents are expected to pay extra for hairdressing and chiropody at a cost from £8 - £20. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. This unannounced inspection took place over the course of 7 hours. Prior to the inspection the home provided a completed Annual Quality Assurance Assessment, (AQAA), and records and previous reports about the home held by the Commission were read. During the inspection a tour of the premises was undertaken, staff practice was observed, records and files read and checked and residents and their visitors consulted. These visitors included friends, relatives and health care professionals. What the service does well: Broadland House is a warm and friendly home where all the staff work hard to make sure that people living there are comfortable and well looked after. Good information about the home is available for prospective residents and everyone who comes to live at the home has their needs assessed. People have their health care needs met, and they are treated with dignity and courtesy by a caring and trained team of staff. There are enough staff on duty to make sure that peoples needs are met. The staff team are mostly long serving and staff turnover is low. It is of particular note that many people were observed visiting their friends and relatives living at the home during the inspection. Everyone consulted said that they are always made welcome and offered a cup of tea when they visit. It is clear that the home’s welcoming atmosphere encourages people to visit and they enjoy their time there. People living at the home make choices in their daily lives and the food is of a good standard, with plenty of fresh fruit and vegetables routinely used. Any complaints that people have are listened to and action is taken appropriately. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is no doubt that this is a warm and caring home that has significantly improved its health, personal care and care planning. Unfortunately there are still issues relating to Quality Audit and Health and safety, which adversely affect the overall rating of the home. Five requirements and seven good practice recommendations have been made at the end of this report as follows; Requirements • • • • • All Health and Safety checks, drills and tests must be kept up to date Peoples individual toiletries must be separately stored and labelled Soap dispensers should be available in communal toilets A number of Health and Safety issues identified in section 38 of this report must be addressed Regulation 37 reports should be regularly sent to the Commission and audited Recommendations Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 7 • • • • • • • The Needs Assessment form should be more detailed The home should consider using a pre-dispensed system of medication An organised programme of activities should be available. A record of minor complaints, comments and compliments should be kept and audited The good recruitment practices in “Safe and Sound” should be adopted by the home An overview of staff training should be kept by the home The annual quality report covering all aspects of the homes services should be available in the home and used to plan the way the home develops 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. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 8 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 Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 9 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, 2, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides good information about its services to people thinking about coming to live there. People have their needs assessed and are given a contract which clearly tells them about the service they will receive. EVIDENCE: The home has worked to improve its Service User Guide . Inspection of this demonstrated that it is well written and clearly presented. The home is planning further improvements to include photographs of the home and its facilities. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 10 A detailed contract was found in place, which clearly states the services provided by the home. This contract is of particular importance for people paying privately for their care. Details of needs assessment were seen in files inspected. The assessment documentation provides plenty of room for detailed notes to be taken. Further examination of the document showed that some areas of needs are not always detailed and the form could be expanded to include this detail A recommendation has been made in this respect. The home does not provide intermediate care. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of dignity and respect are put into practice. EVIDENCE: The home has worked hard since the last inspection to improve its care planning. All Care Plans inspected were of a good standard, were readable, up to date and person centred. Falls risk assessments are in place, as are other assessments of need and risk. Evidence of regular review was also seen. Life history work is being undertaken to help the home provide a service that reflects people’s individual wishes and needs. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 12 Evidence of good health care support was seen. People’s individual care records contained details of health care needs. Visiting health care professionals were interviewed during the inspection and said that the home asks for help appropriately and maintains the treatment programmes recommended well. The home has implemented MUST nutritional screening and is actively working to improve nutrition of those residents at risk. A variety of health care professionals visited the home during the inspection, and records demonstrated people fully accessing their health care entitlements. Medication is administered using an old style system, with medicines dispensed from individual packets rather than a blister pack system. Evidence that medication is audited and checked was seen. A medication round was observed. The person administering medication was seen to be careful and professional in her duties. Of particular note was the use of preventative pain relief prior to the district nurse attending to a dressing, which demonstrated a thoughtful and proactive approach to care. Staff were observed treating residents with respect and courtesy at all times. Numerous visitors to the home were interviewed who confirmed that this is consistent practice. People have either a telephone in their own room or use the mobile telephone from the office to take private calls. Residents and their relatives confirmed that their clothes and personal possessions are taken care of and do not get lost. Post was seen being distributed unopened to people living at the home. Screening is in place in shared rooms to ensure individual privacy during personal care. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices in their daily lives. A range of activities are available and visitors are warmly welcomed to the home. EVIDENCE: A programme of entertainers was displayed in the hall. Observation of the home and discussion with residents and their visitors demonstrated that a variety of group and individual activities take place, but there is no formalised programme. A recommendation has been made in this respect. Those people that are able to, remain involved in daily life activities such as laundry, cooking and taking care of their own rooms. A grant has been gained to develop the garden, with the intention of making a relaxing and stimulating outdoor environment. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 14 During the inspection a large number of people came to visit their relatives and friends at the home. Discussion with residents and their visitors demonstrated that people are consistently warmly welcomed and supported by the staff team. The home is to be commended for making people feel so relaxed and welcome. Some people at the home go out on their own to the local shop and for walks. People living at the home said that they were able to bring their own possessions with them when they came to live there. They said that they can decide what they want to do and how they live their lives. Some people choose to stay in their rooms and staff bring them their meals and refreshments. Inspection of the kitchen found it to be clean, tidy and a large delivery of good quality fruit and vegetables was seen arriving. A rolling menu of traditional foods has been developed according to nutritional advice. A menu board has been purchased for people to see what is the main meal of each day. People at the home said that they were not consulted about the content of the menu, but that they are happy with the food and that they have plenty to eat. Individual choice of meal is taken from people each morning. A new layout for the dining room includes staff sitting at tables with people to assist or prompt people who may have specific dietary needs. Mealtimes were observed to be relaxed and happy occasions and staff were seen being appropriately supportive of people who needed assistance with eating. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a good complaints procedure and are protected by a trained staff team. EVIDENCE: The home has recorded two complaints in the past year, which were appropriately recorded, and action taken. The home does not currently keep a record of minor complaints, comments, suggestions and compliments. A recommendation has been made in this respect. Evidence of staff training in adult protection and whistle blowing was seen. This training is updated annually. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a well-maintained environment, which is homely and comfortable. There are currently shortfalls in some health and safety records and in storage of some personal care items. EVIDENCE: The home itself is homely, well maintained and tidy. Signs around the home assist people with dementia care needs to find their way around. A grant has been obtained to make the garden an accessible, stimulating and enjoyable environment. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 17 Inspection of some safety records demonstrated that these are not currently all up to date. Examples were; • No resident fire drills have been undertaken • The call system is not regularly checked. • No evidence of recent boiler servicing could be found. • The electrical wiring certificate appeared to be out of date. A requirement has been made in this respect. The home was found to be clean, hygienic and pleasant. Two shortfalls were found as exceptions to an otherwise good environment. Sinks in shared rooms did not have separate labelled areas for each person to keep their own soap, toothbrush etc • Ordinary bars of soap were in communal toilets rather than dispensers. A requirement has been made in respect of these issues. The laundry area is small, but well organised and equipped. Clothes and soiled linens were found appropriately sorted. People report that their clothes are carefully laundered and that items do not get lost. • Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are available In sufficient numbers to look after people living at the home. The home has improved its standards of vetting and offers training to its staff. EVIDENCE: Inspection of staff rotas, observation of the home during the inspection and discussion with people living at the home demonstrate that there are enough staff on duty to meet peoples needs. The manager reported that everyone working at the home has either achieved, or is in the process of achieving an NVQ qualification in care. The senior team have received more advanced training and the manager is hoping to achieve her RMA this year. Inspection of recent staff files demonstrated that the home has improved its standards of recruitment since the last inspection. Two references were found in place for recently appointed staff as well as POVA and CRB clearances. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 19 Further good recruitment practice was discussed with the senior team, and a copy of “Safe and Sound” good practice guidelines was left at the home. A recommendation has been made in this respect. Evidence of staff training and induction was seen in staff records. Staff were seen working in a professional and conscientious manner. The manager said that the home has a dedicated trainer who ensures that training is kept up to date. These records are not kept at the home. A recommendation has been made in this respect Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 20 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is generally good. However recent lapses in audit and review mean that people cannot be sure that all aspects of the home are safe. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 21 EVIDENCE: The home’s manager has recently been on maternity leave and the senior team has run the home in the interim. The manager hopes to complete her RMA on her return. Prior to going on maternity leave the manager had begun to develop a system of management quality audit. Unfortunately not all aspects of this audit have been maintained in her absence. This lapse appears to have been caused by oversight or misunderstanding, rather than any lack of professional conduct on the part of staff currently running the home. A recommendation has been made in this respect. The provider submitted a short Quality Assurance report following the inspection. This demonstrated that some aspects of the home are being quality monitored. This work needs to be expanded to cover all aspects of the home and the services it provides A recommendation has been made in this respect. Money is not generally held on behalf of people living at the home. People’s finances are run by their relatives or legal professionals. Some residents have small amounts of cash held in the office. A sample were checked and found to be accurately and carefully recorded. Some issues relating to safe working practice were identified; Evidence of mandatory health and safety training was seen, but in at least one instance it appeared to be lapsed. This may have been be due to inaccurate recording, but should be checked. • No record could be found of recent boiler servicing. • Window restrictors had been installed, but did not prevent windows opening fully (This was rectified by the recently appointed handyman during the inspection) • The electrical wiring certificate was out of date • The laundry door was not secure leaving potential access to detergent blocks by people with dementia care needs • Soaps and shampoos were on open shelves in the bathrooms, again causing potential risk. • Issues relating to infection control have been identified elsewhere in this report A requirement has been made in this respect. • Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 22 It was noted during the inspection that not all notifiable incidents have been reported to the Commission. A requirement has been made in this respect. On a more positive note, the home has implemented the requirements of the last report in relation to providing radiator guards, boxing in hot pipes and ensuring fire doors shut fully. Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 17 X 18 3 2 3 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 24 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 OP38 Regulation 13 (4, c) Requirement The registered person must ensure that unnecessary risk to the health or safety of residents are identified and so far as possible eliminated. In particular, the areas of shortfall identified in sections 36 and 38 of this report must be addressed. Repeated Requirement All checks, tests and drills relating to health and safety must be regularly made and records kept. People living in shared rooms must have separate and named storage areas for their toiletries and personal care items. Soap dispensers should be available in communal toilets. All notifiable incidents must be reported to the Commission. Timescale for action 31/12/07 2. OP19 13.4 (C) 31/12/07 3. OP26 13.3 31/12/07 4 5 OP26 OP38 13.3 37 31/12/07 31/12/07 Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP3 OP12 OP16 OP29 OP30 OP33 Good Practice Recommendations The needs assessment form should be expanded to identify all aspects noted in this standard. The programme of activities should be organised and details given to residents in advance A record of minor complaints, comments suggestions and compliments should be kept and audited to help identify areas in which the home could improve its service. The good practice guidelines of “Safe and Sound” should be adopted by the home An up to date overview record of staff training should be kept at the home The Annual quality report covering all aspects of the homes services should be kept in the home, given to residents and their families and used to develop the homes annual plan Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Broadland House DS0000059149.V353755.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!