Inspection on 24/11/05 for Broadlands Park

This inspection was carried out on 24th 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 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 Park 20/03/09

Broadlands Park 10/12/07

Broadlands Park 17/07/07

Broadlands Park 21/08/06

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 Mr Pearson Clarke Unannounced Inspection 24th November 2005 11:30 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 Park DS0000027357.V268293.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 Park DS0000027357.V268293.R01.S.doc Version 5.0 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.V268293.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Old age not falling within any other category 21 Dementia 3. One person with mental disorder who will be named within the NCSC records. Overall number not to exceed 22. 18th May 2005 Date of last inspection 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. Broadlands Park DS0000027357.V268293.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 took place over the late morning and lunch time period. The inspector spent time with the management, toured the home talked to staff and service users and observed staff working. The atmosphere within the home was calm and relaxed with the majority of service users sitting in the lounges watching television or talking to visitors What the service does well: What has improved since the last inspection? What they could do better: Care must be taken to ensure information relating to care is always made available in such a way as to maintain confidentiality at all times. The Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 6 management must ensure that all staff recruited are subject to a robust recruitment process on all occasions. The providers need to continue to plan ways to make the building fit for purpose. 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 Park DS0000027357.V268293.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 Park DS0000027357.V268293.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): 2,3,5 Prospective service users are given the opportunity to visit the home and the services assessment process allows for good admissions to be made. Service users know what they will pay for the service. EVIDENCE: During the inspection the Inspector tracked the records relating to two recent admissions to the service and talked to the homes manager about the admission process. From these it was possible to see appropriate assessment had taken place and that these assessments allowed the home to confidently make judgements about meeting need. It was clear that it is normal practice for prospective service users and their representatives to visit and assess the home and copies of the homes contact were held in the service users file. Broadlands Park DS0000027357.V268293.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): 8,10 With the exception of visiting dental services the residents health care needs are fully met. Care must be taken to ensure that the delivery of personal care is done in a way which fully supports service users right to privacy and confidentiality. EVIDENCE: Examination of service user plans and discussion with the management indicated an appropriate regime for the meeting of service users health care needs is in place. The one exception to this is access to a dentist who will carry out visits to the home. This was discussed with the manager and whilst the situation is far from ideal the service have done everything that they can to rectify this and are encouraged to continue in their efforts. During the inspectors tour of the building it was noted that instructions to care staff on the delivery of personal care were displayed on the wardrobe doors in some service users rooms. In some cases these rooms were shared and in all cases private and personal information could be seen by anyone going into the room. Whilst the information was designed to ensure all staff followed an agreed care pattern, this is not good practice and not respectful of service users right to confidentiality. Such information must be available in such a way Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 10 as to not compromise privacy and confidentiality, perhaps by being stored in a folder in the room which staff have access to. See requirement Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 11 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 helps residents to exercise choice and control over their lives. Service users are supported in maintaining the contact that they wish with family and friends. Appropriate activity and stimulation is provided. EVIDENCE: Discussion with staff and the management indicated a good level of awareness of the importance of helping service users exercise choice in their daily lives. The home has an open visiting policy maintains a good level of communication with service users families. The manager confirmed that if a service user’s spouse has difficulty in visiting then she will collect them in order to maintain the relationship. The inspector was able to track the approach the provision of entertainment through a detailed log. This showed regular structured activity with visiting entertainers and regular input from staff on duty. In the case of the latter this had included quizzes, reading aloud, singing, nail care and music and movement. Holy communion and a monthly service are held. Broadlands Park DS0000027357.V268293.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): 18 The service has an appropriate approach to adult protection. EVIDENCE: The majority of staff at the home have received adult protection training in support of the homes policy and procedure in this area. The service manager confirmed that further training was planned and that this would include all staff recruited since the last round of training. Broadlands Park DS0000027357.V268293.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): 19,26 Whilst longer term solutions to the problems posed by the building are still to be finalised, service users live in a generally comfortable, clean and homely environment. EVIDENCE: Whilst this inspection did not focus on the environment the inspector did tour the public areas of the building and some bedrooms. The building was clean and tidy with no noticeable odour. Since the last inspection the provider has complied with a requirement to improve access to the garden and a new ramp has been installed at the front door. The requirement to submit timed proposals for the buildings future have not been fully met in the given timescale, nonetheless the Commission is aware of the efforts being made by the providers in this respect and as such the requirement is repeated with an extended timescale. Broadlands Park DS0000027357.V268293.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): 29 In order to offer full protection to service users the provider must follow a robust recruitment process at all times. EVIDENCE: The inspector tracked the employment records of the two most recent appointments. Although the process as designed is satisfactory it was noted that both applicants had references outstanding , but had still commenced work. The inspector was assured by the manager that they would both be working under supervision until their criminal record bureau checks were received and references were returned. Whilst the Commission will accept staff working in a supervised manner once they have had a POVA First check, this is on the understanding that all other parts of the recruitment process are robust and this includes the need to obtain references before working. See requirement Broadlands Park DS0000027357.V268293.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 Broadlands Park offers a caring resident centred service. EVIDENCE: These standards were not inspected in any depth on this occasion, however the inspector judges that service users needs and wishes are kept to the fore. Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 16 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 3 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 2 X X X X X x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X x Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 17 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 OP19 Regulation 23 Requirement That the providers submit to the registration authority detailed and timed proposals as to how the environment can be so adapted as to remove the problems relating to changes of level and difficult access to the first floor That information relating to personal care is made available to staff in such a way which does not compromise the privacy and right to confidentiality of service users. That a robust recruitment process is followed on all occasions. Timescale for action 31/08/06 2. OP10 12 24/11/05 3 OP29 19 24/11/05 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 Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 18 Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 19 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 Broadlands Park DS0000027357.V268293.R01.S.doc Version 5.0 Page 20 - 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. 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