Inspection on 15/12/05 for Broadlands Nursing Home

This inspection was carried out on 15th December 2005.

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

Broadlands Nursing Home 12/06/07

Broadlands Nursing Home 16/06/06

Broadlands Nursing Home 01/08/05

Broadlands Nursing Home 25/11/04

Broadlands Nursing Home 13/09/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Broadlands Nursing Home 51 Burdon Lane Cheam Surrey SM2 7PP Lead Inspector Margaret Lynes Unannounced Inspection 15th December 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broadlands Nursing Home DS0000019080.V273501.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. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadlands Nursing Home Address 51 Burdon Lane Cheam Surrey SM2 7PP 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) 020 8661 1120 020 8661 1768 Mr N Baloo Mrs Anita-Marie Porter Care Home 25 Category(ies) of Dementia (25), Mental disorder, excluding registration, with number learning disability or dementia (25), Old age, of places not falling within any other category (25) Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: Broadlands is a pleasant home situated in a quiet residential area close to Cheam village. It is situated close to public transport links, including rail services and motorways. The home provides nursing care for elderly, mentally frail, residents. There are some nine double bedrooms and seven single. The majority of the bedrooms are situated on the ground floor. There is a large, attractive and well-kept garden, overlooked by a spacious conservatory in which the residents take their meals. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this visit, carried out over the course of several hours, was to determine if the home had taken action to resolve the requirements that were made following the inspection in August, and were still outstanding at an additional visit made in September. The report of the August inspection contained 12 requirements, while an Immediate Requirement notice was left with regard to fire safety. The additional visit in September was to determine if the Immediate Requirement notice had been complied with – it had not, in spite of a four-week extension being granted to the initial completion date on the notice. This was, not surprisingly, of considerable concern to the Commission, and while the notice was, eventually met, it was disappointing that the proprietor did not take action until considerable pressure was put upon him. At that visit in September, a further four requirements were made. Compliance with these four requirements will be considered at the next inspection visit. Of the 12 requirements mentioned above, the home has now taken action to meet seven of them. This is commendable however it is of concern that two of those that remain outstanding relate to medication administration and wound care. Both are of vital importance and it was disappointing that errors were still noted, albeit some improvements had been made. One relates to staffing levels, as a shortage of qualified staff was noted on one occasion. What the service does well: What has improved since the last inspection? What they could do better: As already mentioned, five of the requirements were unmet. These related to the need to install a lock on one of the bathroom doors; the need to ensure that medication administration records were accurately completed; to ensure that wound care documentation was up to date; the need to ensure that Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 6 staffing numbers are maintained at the agreed levels and, finally, for the proprietor to carry out a monthly visit to the home and to make a report of each visit. These are all requirements that have been raised before, and a concerted effort is needed to ensure that appropriate action is taken. 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. Broadlands Nursing Home DS0000019080.V273501.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 Broadlands Nursing Home DS0000019080.V273501.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): Not assessed on this visit. EVIDENCE: Broadlands Nursing Home DS0000019080.V273501.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): 8 and 9 In spite of previous requirements, staff were still not fully completing wound care documentation. This means that it is feasible that not all staff will be aware of the specific treatment to be given, which in turn can have a detrimental effect on the service user. The medication administration records were examined. Unfortunately a number of errors were again noted. Clearly this is unacceptable, as any mistakes made in giving out medication can have serious consequences for the service users. EVIDENCE: The documentation re wound care was good, but as on previous visits it was evident that staff were not always recording follow up care, which means that it is difficult to determine if the planned care had been fully completed. A number of gaps were again found in the medication administration records. Additionally, staff were not always recording why medication had not been given. Although the number of errors has decreased, qualified staff should not be making any mistakes in this crucial area. Broadlands Nursing Home DS0000019080.V273501.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): Not assessed on this visit. EVIDENCE: Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 11 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): Not assessed on this visit. EVIDENCE: Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 12 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 and 24 Steps have been taken to meet five of the six requirements that were made relating to the environment. Once the outstanding requirement has been met the home will fully meet these Standards. EVIDENCE: The previously made requirements related to the need to ensure that the patio surface was levelled; the need to ensure that bedroom doors were not wedged open; the need to ensure that all emergency call bells were within reach; the need to ensure that thermometers were available for staff to check the temperature of bath water; the need to install a lock on the first floor bathroom door and the need to ensure that appropriate locks were fitted to bedroom doors. The area of the patio causing concern has been levelled however there is still a small step which the manager quite rightly pointed out was also a hazard. She will look at ways to make this safer. After an Immediate Requirement notice, and additional pressure from the Commission, the proprietor eventually Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 13 purchased fire safety closure devices for those bedroom doors that service users wanted to be kept open. The manager was advised that if the lounge door was to be kept open, a similar device needed to be installed there also. On walking around the home, all call bell cords, with one exception, were untied and within reach. The exception related to one cord that although untied was quite short. The manager was advised to replace it. A new thermometer had been purchased for staff use, while within the service user plans it is now noted where service users have either opted not to have a lock on their door, or have been risk assessed as unable to manage to use a key. The manager was asked to ensure that a comment was inserted into the Statement of Purpose and the Service User guide so that it was made clear that bedroom doors in the home were not fitted with locks, although this could be reviewed depending on the needs/wishes of the individual client. One requirement remains outstanding – the need to fit a lock to the first floor bathroom door. Indeed, locks need to be fitted to two doors – the main entry door to the bathroom, and the door leading into it from the bedroom. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 14 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 and 30 From the rotas provided the Inspector was not fully satisfied that the number of staff on duty would result in the service users needs being consistently met. In line with the previously made requirement the manager is now keeping a record to evidence that staff have read the relevant policies and procedures. This means that the staff team should be fully informed about the methods of working in the home, which in turn should have a beneficial effect on service users. EVIDENCE: The rota provided indicated that the staffing levels on all but one occasion were in line with the previously agreed levels. These levels should be 2 qualified staff with 4 carers on duty in the morning; one qualified nurse with 4 carers on duty in the afternoon/early evening; and 1 qualified nurse with 2 carers on duty overnight. In this home, unusually, the manager works as part of the rota. On just one occasion (on the rota provided) it was evident that there had not been the requisite two qualified staff on duty in the morning. As mentioned above, a record is now being maintained which indicates when/which staff have read the homes’ policies and procedures. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 15 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): 33 and 35 The Inspector was not fully satisfied that the home was being run in the best interests of the service users as the proprietor was still not carrying out the requisite monthly visits and reporting in writing. Concerns were raised in previous reports regarding the safekeeping of service users valuables. On this visit the Inspector was satisfied that the arrangements were adequate. EVIDENCE: Part of the quality assurance should be the monthly visits by the Registered Person (or their nominee). Previous requirements have been made re the need to ensure that these visits are carried out as prescribed in the Regulations. As stated in the last report - although the frequency of the visits has improved, written reports are still not being produced. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 16 While the home does not have a safe, valuables are securely locked away, and only the manager has a key. It was felt, therefore, that the storage arrangements were satisfactory. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 17 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 X 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 2 X X 3 X X STAFFING Standard No Score 27 2 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X 3 X X X Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 18 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 OP8 Regulation 13 Requirement The manager must ensure that wound care documentation is kept up to date at all times. The previously set timescale has not been met. The manager must ensure that medication administration records are accurately kept at all times. The previously set timescale has not been met. A suitable lock must be fitted to the first floor bathroom door. The previously set timescale has not been met. Staffing levels must be increased so that the minimum levels previously agreed are maintained at all times. The Registered Person must ensure that they (or their nominee) visit the home on a monthly basis and that a report of each visit is produced. The previously set timescale has again not been met. Timescale for action 15/12/05 2. OP9 13 15/12/05 3. OP21 12 31/12/05 4. OP27 18 15/12/05 5. OP33 26 15/12/05 Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 19 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 Refer to Standard OP19 OP19 OP19 OP19 Good Practice Recommendations Consideration should be given to ways to make the small step on the patio more visible/safer for service users. The emergency bell cord in the ground floor WC should be replaced. If the lounge door is to be kept open at all times then a suitable fire safety closure device needs to be installed. It should be made clear in the Statement of Purpose and the Service User guide that the bedroom doors in the home are not fitted with locks. Broadlands Nursing Home DS0000019080.V273501.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Broadlands Nursing Home DS0000019080.V273501.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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