Inspection on 17/07/07 for Broadlands Park

This inspection was carried out on 17th July 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 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

Broadlands Park 20/03/09

Broadlands Park 10/12/07

Broadlands Park 21/08/06

Broadlands Park 24/11/05

Broadlands Park 18/05/05

Broadlands Park 01/03/05

Broadlands Park 27/05/04

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 Broadlands Park The Green Upton Norwich Norfolk NR13 6AZ Lead Inspector Hilary Shephard Key Unannounced 17th July 2007 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 Broadlands Park DS0000027357.V346350.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. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadlands Park Address The Green Upton Norwich Norfolk NR13 6AZ 01493 751521 01493 751833 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) Mr Raymond Hollyman Mrs Susan Hollyman Mrs Michelle-Lee Hemaz Care Home 22 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (21) of places Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Broadlands Park is a care home providing personal care and accommodation for 22 older people of whom up to 4 may also have dementia. It is a privately owned and run residential care home. The home is located in the rural Norfolk village of Upton. The service is long established and is based in a period house, with accommodation on the ground and first floor. The home has large gardens to the front and rear, although only those at the front of the building are used by residents. The home has single and double bedrooms all of which are ensuite. The current scale of fees charged are from £288 - £345 per week. Residents are expected to pay for their own toiletries and hairdressing. Broadlands Park DS0000027357.V346350.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 care outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the 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 the current judgments for each outcome group. A total of 6 requirements were made as a result of this inspection. This home has a complicated layout that has an impact on residents who are frail, disabled or cognitively impaired. The proprietors are aware of this and for many years have been considering how this could be improved. Requirements regarding the premises have been made following a number of inspections but the proprietors have been slow to make improvements. Work on the extension for which planning consent was granted in early 2006 has still not commenced and this means that all the other planned changes regarding the premises are delayed. What the service does well: The manager or deputy visits residents before admission to gather information about their care needs. This information is then used to help plan how best to meet their care needs. Staff are very kind and caring and residents say they are happy here. The food is of good quality and enjoyed by the residents. Residents’ relatives who responded to the Commissions quality survey indicate the food is excellent and there is a very good choice of meals. Residents are able to choose how they spend their days and are satisfied with the lifestyle they are provided with. Staff are competent and are encouraged to undertake a variety of training relevant to the residents care needs. Staff are also supplied in sufficient numbers enabling them to provide good care to residents. Residents relatives who responded to the Commissions quality survey indicate the staff are good and provide a good quality of care. Care planning for residents who do not have complex care needs was satisfactory, but was not detailed enough for those with more complex needs. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 6 The manager deals with residents and relatives concerns in a professional way. What has improved since the last inspection? What they could do better: 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. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 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 Park DS0000027357.V346350.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good quality outcomes in this area. Prospective residents by having their care needs assessed by a competent person and by this information being used to help plan how their care needs are to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The previous inspection carried out in August 2006 found that care records contained evidence that prospective residents had their care needs assessed before they were admitted. The July 07 inspection found this practice continues. The manager visits prospective residents and completes a full assessment. Information about residents care needs is also obtained from the person’s social worker. All the information gathered is then used to help plan how the residents’ care needs are to be addressed. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience poor quality outcomes in this area. Residents are being placed at risk from potential harm to their health because of unsafe medication practices. Residents with complex care needs such as dementia are not benefiting as much as they should because of inadequate care records and written guidance about their care needs. The current layout and design of the premises are having a detrimental effect on one resident’s wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Previous inspections have identified that residents’ care records contained useful information about their assessed care needs. Care records also included risk assessments for falls and moving and handling. Residents’ healthcare needs were being met and healthcare professionals were involved in their care as necessary. Residents and relatives were satisfied the care they received was good. The July 07 inspection found care records for the residents who have dementia were not detailed enough for staff to have a good understanding of how to meet residents’ full range of care needs. However, the records did contain Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 10 good information about residents’ life histories and some of this information is being used in meeting residents social care needs. The care records of one resident, who is now confined to her bedroom, (see Environment section for further details) did not contain enough information about how staff should be meeting her emotional or social needs. The care records also indicated the resident was at risk of developing pressure sores but there was no assessment carried out to identify how at risk she was and there were no guidelines to say what type of pressure relieving equipment was to be used. Records stated she should have bed rest twice a day and staff should monitor her pressure areas. Staff said they were unable to monitor this resident’s weight because she cannot stand on the scales and the home does not have any sit on scales. Because there is no lift, it would be unlikely that sit on scales could be used anywhere other than the ground floor. Care records contained good assessments of residents’ nutritional needs and in one case a food diary was being completed. This enables staff to easily see how much this person was eating and the manager used that information as a monitoring tool. The resident’s care record however, did not contain much information about their food preferences or offer any guidance as to the food they liked to eat. The care records indicated this resident is significantly underweight but failed to contain information about how staff should be adding extra calories and protein to their food. The manager has just completed training in using an in-depth nutritional screening tool and is making some changes to residents’ nutritional intake. This should help to improve residents’ general health. Previous inspections have found medication records to be maintained accurately and appropriate storage in place with the exception of storage for controlled drugs. The July 07 inspection found the way staff were administering medicines was potentially unsafe and placed residents at risk of receiving the wrong medication. Medicines are supplied on a weekly basis by the local medical centre. The pharmacist places tablets into a monitored dosage type compliance aid. This system is designed to enable staff to give medication at the correct time and day. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 11 However, staff said it is usual practice for the manager to remove some tablets and liquids that cannot be put into these containers into medicines pots. The manager then labels the pots and stores them in a locked cupboard until they are due to be given. Prior to the medicine round, tablets are removed from the pharmacy filled containers into pots and are then taken round on a tray and administered to the residents. The medical centre refills the containers weekly, but they expect staff to take the containers back before the week’s supply has finished so they can be refilled. Each week the manager takes the remaining tablets out of the containers and into labeled pots and into a locked cupboard ready for the lunchtime medicine round. This potentially unsafe practice means staff are dispensing medicines hours before they are due to be given, in order to meet the needs of the medical centre. The practice of putting pharmacist-dispensed medicines into labeled pots creates a potential risk that staff could mislabel the pots or put the wrong medicine in the pots. It should also be noted that the person putting the medicines into the pots is not always the person who administers them. Observations made of the lunchtime medicine round showed staff were very careful when they gave out tablets to residents, but did leave the tablets unattended and accessible to residents for a short period of time. One resident has been prescribed a controlled drug for pain relief. Storage of this was checked and was found to be unsuitable and not in accordance with the Misuse of Drugs Act 1971. The controlled drug register showed the correct number of medicines being stored, but because there is no administration record for this drug, it was not possible to check its correct administration. Medication Administration Records (MAR) were checked and showed that the administering details of some medicines being given had not been completed by the dispensing chemist. This was the case for the controlled drugs and many other medicines regularly prescribed for residents. There was no reason for this practice other then the dispensing chemist had failed to provide administration details on the MAR charts. Staff said in these cases they usually administer according to the instructions on the box, packet or bottle of medication. This means that staff had to write the administering details on the MAR charts but in the case of the controlled drug they had not done that. This also creates a potentially unsafe situation as staff could misread the administration instructions on the boxes and give the resident an incorrect dose. It was not possible to check if residents have been receiving the correct amount of tablets as those tablets being carried forward from previous weeks were not being recorded as such on the MAR chart. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 12 Staff advised they have training in how to administer medication and are assessed by a senior staff member before they can give out medicines on their own. Residents continue to say they are treated with dignity and respect. Observations of staff interaction with residents showed this to be the case. Staff were seen to be careful and gentle when assisting residents. Requirements have been made about care planning and medication. A referral to the Commission’s specialist Pharmacist Inspector has been made. Broadlands Park DS0000027357.V346350.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): 12,13,14,15 People who use the service experience good quality outcomes in this area. Residents benefit from the provision of good food and being able to lead a lifestyle of their choosing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Previous inspections carried out have found that residents enjoy the food and their lifestyle. The July 07 inspection found this continues to be the case. During the morning, observations showed that staff were making every effort to engage residents in some form of occupation and activity, mainly one to one discussion. A volunteer was attending to residents’ nails, which they enjoyed. During the afternoon outside entertainment had been arranged in the form of a musician singing songs from the past. Residents who wanted to participate were enjoying this and staff were also seen to interact well with residents. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 14 One resident spoke of how she was free to do what she wanted when she chose and was happy to be there. One relative spoke of how her relative was well cared for. Staff spoken with showed a good understanding of looking after the residents and making sure their emotional and social needs were being addressed alongside their physical care needs. Lunch was observed and residents seemed to enjoy their meal and a relative spoke of how their relative is provided with good food to his liking. Fruit and drinks are available to residents at all times throughout the day, which they said they appreciated. It would further enhance residents’ independence if jugs of drinks were made available on the dining tables during mealtimes. The manager spoke of how she is making changes to the food to improve residents’ nutritional intake. To ensure residents nutritional needs are fully met, further work needs to be undertaken with care planning and adding extra calories and protein to food for those who need it. Relatives continue to be made welcome in the home and are involved in their relatives care as much as they wish to be. Broadlands Park DS0000027357.V346350.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): 16,18 People who use the service experience adequate quality outcomes in this area. Serious issues and concerns are dealt with professionally by the manager, but residents are being placed at risk from potential harm because staff are not fully checked before they start work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Previous inspection carried out August 06 found the home had a suitable complaints procedure, but most residents had forgotten about its’ existence. Residents and their relatives said they were confident about approaching the manager with concerns. Staff had received training in protecting people from abuse. The July 07 inspection found that residents and relatives concerns continue to be well managed. Staff spoken with said they would have no hesitation to report any concerns to the manager or the proprietor and were confident these would be addressed. Staff said they have had training in protecting people from abuse and knew how to recognise the signs of abuse. Staff records showed some inconsistencies with pre-employment checks not being fully completed; see “Staffing” for further detail. Broadlands Park DS0000027357.V346350.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): 19,26 People who use the service experience poor quality outcomes in this area. The confusing layout of the building and the difficulties with access make the premises unsuitable for any resident with significant disabilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The proprietors have owned the home for approximately 20 years and have been constantly aware of the difficulties experienced by residents because of the access within the building. Residents’ bedrooms are located on both ground floor and first floors and first floor access is via stairs, there is no shaft lift. There is a stair lift however, but residents still need to access their rooms via steps, sometimes two or three, so they need to be very able bodied. There are also a significant number of shared bedrooms, some of which are very small and oddly shaped. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 17 The inspection carried out in May 2004 found the proprietors very aware of the difficulties with the layout of the home and of the need to make improvements. At this time the Commission considered imposing conditions on their registration relating to the type of residents that could be admitted if suitable plans for improving the premises were not developed. This was because there were outstanding requirements from previous inspections for the proprietors to improve the access within the home. The Commission had extended deadlines for these improvements, but the May 04 visit showed nothing had been done to enhance the premises apart from some redecoration. The May 04 visit showed that residents experienced difficulties with access to the gardens and ground floor toilets and requirements were made regarding this. That visit also identified unguarded radiators, which posed a risk of harm if residents were to fall upon them and a requirement was made. In total 7 requirements were made following that inspection regarding the premises, one of which was outstanding from previous inspections. The inspection carried out in March 2005 found that the proprietors continued to explore the options for the future development of the premises. They still needed to provide residents with level access, suitable ground floor toilet facilities and a gentler ramp for access to the gardens. The requirements made at the previous inspection regarding access, toilets and garden access had not been complied with. The inspection carried out in May 2005 found the proprietors were starting to put together plans to improve the premises. They were looking at building an extension and extensively refurbishing the current building. The requirements made at the March 05 inspection regarding ground floor toilets and garden access had not been fully complied with. The staff toilet near the dining room was being used for residents, but the access to that remained difficult and the proprietors still had not addressed the access to the garden. A requirement was made for the proprietors to submit detailed, timed proposals as to how the environment is to be adapted to remove the problems relating to changes of level and difficult access to the first floor. The inspection carried out in November 2005 found that the access to the gardens had been improved, but no other changes had been made to the premises. The proprietors had not submitted their plans for the improvements to the premises and had therefore not complied with the requirement made at the previous inspection. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 18 The inspection carried out August 06 found that planning permission had been granted for an extension to the property to include rooms to which existing residents could be transferred. Once the extension is completed further work is planned with a view to adapting the property and making it more suitable to the needs of its residents. The proprietors were required to provide plans detailing how transition was to be made. They were also requested to consider how to reduce the number of double rooms in the home. The communal areas were noted to be clean and tidy, but there were some unpleasant odours noted in the corridors to the back of the house. A meeting was held in Dec 06 with the proprietors to discuss their plans for the new extension. They said the main house needed major refurbishment and they needed the resident numbers to become 18 before that could take place. The home’s annual quality assurance assessment received in June 07 indicates that they feel the home offers a homely, clean and warm environment. They encourage residents to bring in their own effects and belongings. The stated they have improved the premises by providing new dining room furniture and carpeting, redecorating and a new stair lift. They also plan to improve the premises by building a new extension, refurbish main building by levelling the floors, installing a shaft lift, providing more office space. They also plan on improving bathing facilities and the lounges and dining room. The July 07 inspection found no changes made to the layout or design of the premises. The manager was unable to give any date for the extension or refurbishment of the current building. The proprietors had indicated they would be starting work once resident numbers had reduced to 18 and there were 19 residents living in the home on the day of this inspection. The majority of bedrooms are in need of refurbishment because they are looking well worn and poorly maintained. The home was clean, but the shabby décor makes it appear dirty. The wood panelling in the dining room makes it very dark, which could create difficulties at mealtimes for residents with poor sight. The lounge areas offer residents a comfortable area where they tend to spend most of their time. A new carpet has been laid in the dining room and new furniture was on order. The old stair lift has also been replaced. The confusing layout and difficulties with access continue to make the home unsuitable for people with physical, visual or cognitive impairment. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 19 Because of the difficulties with access to the ground floor one person is now unable to leave her bedroom. This person has become immobile and staff are now unable to bring her downstairs because of the layout and design of the building. There is a steep step she would need to negotiate before she could access the stair lift, however because of her mobility problems it is unlikely she would be able to use this lift. It is very unfortunate that the layout of the premises is having a detrimental impact on this persons well being. A requirement has been made regarding the premises. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 People who use the service experience poor quality outcomes in this area. Although residents benefit from being cared for by competent staff, they are at risk from potential harm because new staff are being allowed to work at the home without any proper checks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Previous inspections have shown there to be sufficient numbers of competent and qualified care staff to meet the care needs of the residents. The July 07 inspection found this continued to be the case. Staff spoken with confirmed they receive training and observations showed they were competent in carrying out their care duties. One member of staff was observed to lack understanding of how to approach residents and was abrupt and sharp in her manner. However when spoken with this member of staff showed a very good understanding of residents’ care needs, particularly how to approach those who have dementia. A relative spoke of how nice the staff are and how respectful they are towards the residents. Records of new staff contained documents relating to their induction indicating they are being shown how to care for the residents. The manager advised that out of 17 care staff, 8 have achieved NVQ 2. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 21 Three inspections carried out in 2005 found new staff were being allowed to start work without being properly vetted. The inspection carried out in August 2006 found this practice had improved and staff had been properly checked before starting work. Staff records of two newly appointed staff were checked at the July 07 inspection for evidence that the home is using safe recruitment procedures. These showed that again, staff were being allowed to start work in the home without being properly checked. In one case, a carer was allowed to start work before the home had received any written references or criminal records checks. Evidence on the recruitment file showed this person’s Criminal Records Bureau (CRB) check had not been applied for until they had worked at the home for over 5 weeks. This means that staff have been allowed to start work at the home without any proper checks made on them at all, putting residents at a serious risk from potential harm. A requirement has been made regarding recruitment practices. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38 People who use the service experience poor quality outcomes in this area. Although the manager is experienced and qualified, residents health, safety and well-being is compromised because of a poor and unsafe environment, unsafe medication procedures and a failure to properly check staff before they start working at the home. This judgement has been made using available evidence including a visit to this service. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 23 EVIDENCE: The July 07 inspection found no changes with the way the home is managed. The manager advised she has updated her dementia care knowledge and has completed training in assessing residents’ nutritional status and basic care practices. The manager continues to monitor the quality of service that residents receive both informally and formally. Residents meetings are held and the home completes a quality survey yearly. The manager spoke of how she had made changes to the menus because of feedback received from residents. The way the home assists residents with their finances has not changed. Financial records of two residents were checked and were in good order. The inspection carried out in August 2006 found radiators in residents’ bedrooms were uncovered creating a potential risk of burns if a resident fell against them. The July 07 inspection found this was still the case, many radiators throughout the home remained without covers. The manager advised that covers were in the process of being fitted and said they were being done in batches of 5. The fire officer had inspected the home in May 07 and had made some recommendations for improving the fire safety. He made a follow up visit on 24th July and found these recommendations had not been complied with. An enforcement notice was issued by the fire service with an expectation that fire safety would be improved by 31st August 07. This inspection has again highlighted areas of concern regarding the premises, safety and poor recruitment practices. It is of serious concern that these issues and the fire officer’s recommendations have not been addressed in a timely way. A requirement has been made regarding safety of the premises. Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 24 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 2 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15 (1) Requirement Care records for residents care needs should provide detailed guidance to enable these needs to be addressed. Care records should show that proper provision is made for the promotion of residents’ physical healthcare needs. Safe medication practices should be carried out in order to minimise the risks of harm to residents. Residents’ health and well-being should be promoted and protected by a suitable, safe and well maintained care environment. The health and well-being of residents should be promoted and protected by safe recruitment practices. The care home should be free from hazards to residents’ safety. Timescale for action 31/10/07 2 OP8 12 (1a, b) 31/10/07 3 OP9 13 (2) 06/08/07 4 OP19 23 (1a) (2) 31/10/07 5 OP29 13 (6) 19 13 (4) 31/10/07 6 OP38 31/10/07 Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 26 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 Broadlands Park DS0000027357.V346350.R01.S.doc Version 5.2 Page 27 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. 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