Inspection on 09/11/05 for Broadland House

This inspection was carried out on 9th November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broadland House 26/10/07

Broadland House 17/01/07

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 80 Unannounced Inspection 8th November 2005 10:00 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.V265601.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadland House Address Bridge Road Potter Heigham Great Yarmouth Norfolk NR29 5JB 01692 670632 01692 670632 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 Ms Rita Elizabeth Postle Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Eighteen (18) Older People who may have Dementia may be accommodated. Total number not to exceed 18. 12th April 2005 Date of last inspection Brief Description of the Service: Broadland House is a care home providing personal care and accommodation to 18 older people who may also have dementia. The home is privately owned and has changed hands within the last year. The new owners are experienced providers having two other homes in the area. Broadland House is located in the Broadland village of Potter Heigham and is within walking distance of the shops and other facilities. The service has 14 single bedrooms and 2 double rooms. Six of the single rooms have en-suite toilets. Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was unannounced and the home was represented by the registered manager and later by the provider. During his time in the home the inspector was able to speak to staff on duty, two service users and two visitors to the home and their views have helped inform judgements made. What the service does well: What has improved since the last inspection? What they could do better: Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 6 The consolidation of a permanent registered manager will help provide consistency. The building as a whole is improving however there remain outstanding challenges and the replacement of the carpet on the first floor is important as is the provision of a secure garden area. 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. Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this visit to the service EVIDENCE: Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 The service has effective care plans that establish service users needs and wishes in an accessible way. The arrangements for the management of medication are generally sound although a risk assessment needs to be put in place where individuals choose to self medicate. EVIDENCE: The last inspection of the service identified the need to improve the services care plans. On this visit the inspector sampled plans for three service users and found them to be much improved. The plans seen indicated an approach to care whereby staff promote resident choice Risk assessment and evidence of review were in place. The management of medication was also inspected. Medicines were seen to be securely stored, with policy guidance in place. Sample administration records were seen and were accurately completed, however it was noted that in the case of one man who has chosen to self medicate a risk assessment was not established for the process and a requirement is made. See requirement Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 The service is enabling service users to exercise choice and control where appropriate and to maintain contact with family, friends and representatives. There is social activity available to residents although this would benefit from future development. EVIDENCE: Discussion with the homes management, staff on duty, service users and visitors to the home helped inform the above judgements. Examination of service user plans showed a commitment to offer people choice in their daily lives and this was supported by staff descriptions of how they work. During the day the inspector had the opportunity to talk to the husband of a newly admitted service user. It was clear that he was highly impressed by the overall care provided for his wife, comparing it favourably with other homes she had been in, however what was particularly notable was the providers efforts to ensure he could see his wife. In this respect the staff were collecting and delivering him whenever he visits and enabling him to eat with his wife. The home should be commended for the extra effort being exercised to ensure that the difficulty of separation after many years together is being supported in a sensitive and caring manner. The inspector was told of informal activity that takes place at the home and of planned activity around the Christmas period. The management confirmed that Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 11 they intended to develop a structured programme for the year ahead and the inspector would encourage this to improve the quality of day to day life. Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,19 The service has a satisfactory complaints process. Procedures and training are in place to offer service users protection from abuse. EVIDENCE: The home has had no recent complaints. The provider has a well established staff training programme and an integral part of this is regular adult protection training. Staff spoken to had completed this training and were aware of their responsibilities in this area. Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19.21,26 The service has benefited from some redecoration, refurbishment and work to ensure safety. There are plans to further improve the environment and as an older building there is a need to keep on top of repairs and decoration. EVIDENCE: On the day of inspection the building was clean with no unwanted odour experienced. Since the last inspection the provider has complied with requirements to ensure that water temperatures are fully regulated at the point of delivery. A new conservatory has been added to the lounge and a new assisted bathroom created on the first floor of the home. These are all welcome additions and form part of an overall plan which includes further bedrooms and the creation of a secure enclosed garden. Given that the registration includes dementia then the garden area is important and the provider confirmed that this will happen in the near future. It was noted that the corridor carpet on the first floor of the home was badly rucked and worn. Although it is accepted that this is the area that the new Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 14 bedrooms will be created from and as such the carpet may be damaged, the inspector considers that this carpet must be replaced as it represents a health and safety hazard. See requirement Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 The home has a consistent staff team who are able to meet the needs of those cared for in an appropriate and safe way. Appropriate employment practice is followed by the provider. EVIDENCE: The staffing pattern found by the inspector was consistent with that shown on the rota and the level of cover was sufficient to meet the needs of service users. The inspector spoke to two of the staff on duty, both of whom felt that they worked as part of a good team with sufficient staff on duty to work in an effective way. In both cases they were happy with the training and support given to them and were confident that they understood safe working practice and could deliver it. Sample recruitment records were inspected and they demonstrated a generally sound process. However the record of Criminal record bureau checks applied for was not available as the provider had taken it home to enter information on the previous day. This record has been seen on previous occasions , but the provider is reminded that in order to demonstrate safe practice this evidence must be available at all times. Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 EVIDENCE: The service is currently without a registered manager, however a trainee manager is in place and will come forward for registration in the near future. Although it is early to make judgements about management effectiveness the views of those spoken to on the day were encouraging and the inspector noted that the acting manager conducted the inspection in a competent and efficient manner. The service looks after personal monies for a number of service users and records are kept. Sample records were checked and were generally accurate. However in one case more money was held than shown and care needs to be taken to ensure that records balance. The inspector looked at the arrangements for health and safety in the home. The expected range of policies, procedures and risk assessments were in place, Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 17 however the general working practice risk assessments pre-date the current provider and must be reviewed and updated. See requirement Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 3 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? no 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 OP9 Regulation 13 Requirement That the provider carry out a risk assessment in relation to any service user who wishes to self medicate That the first floor corridor carpet be replaced That the provider review and where necessary update all health and safety policies and risk assesments Timescale for action 30/11/05 2. 3 OP19 OP38 23 12 30/11/05 31/12/05 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 Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broadland House DS0000059149.V265601.R01.S.doc Version 5.0 Page 21 - 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. 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