Inspection on 09/01/08 for Broadlands Residential Home

This inspection was carried out on 9th January 2008.

CSCI found this care home to be providing an Excellent service.

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 Residential Home 07/03/07

Broadlands Residential Home 28/12/05

Broadlands Residential Home 08/06/05

Broadlands Residential Home 10/11/04

Broadlands Residential Home 23/06/04

Broadlands Residential Home 05/12/03

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 Residential Home Borrow Road Oulton Broad Lowestoft Suffolk NR32 3PW Lead Inspector John Goodship Unannounced Inspection 9th January 2008 09:30 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 Residential Home DS0000024346.V357661.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 Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadlands Residential Home Address Borrow Road Oulton Broad Lowestoft Suffolk NR32 3PW 01502 512895 01502 517177 broadlands@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust 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 Ann Elizabeth Maas Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2007 Brief Description of the Service: The stated aim of Broadlands is to provide comfort and companionship in a supportive environment to those older people who require a level of care that is unavailable to them in their own homes. The building comprises a large house, which has been extended, resting on the edge of Oulton Broad, thus offering service users wonderful views over the water. The Homes attractive gardens lead down to the water where there is a jetty to moor boats. The Home offers accommodation for 41 older people, over three floors, all of which can be accessed by passenger lift and the standard of décor and maintenance at the Home was seen to be very good. The current range of fees charged by the home is £341.00 to £600.00 per week. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This was a key unannounced inspection that took place on a weekday and lasted five hours. The manager was present throughout, and they together with other staff on duty were able to assist us to examine records, and care plans, tour the home and be introduced to some of the residents and visitors. The focus of the inspection was to assess the outcomes of the home’s standard of care for residents. This report includes evidence gathered during the visit together with information already held by the Commission. Prior to the visit, we sent out questionnaire survey forms for residents, relatives and staff. 16 residents replied, 8 relatives and 24 staff. The analysis of the survey, and comments made on the forms, have been used in this report under the appropriate Outcome Group. Comments which residents, relatives and staff made to us during the visit have also been included. In addition to remarks made as we went round the home, five residents, including a married couple, talked to us at length, and we interviewed two staff about their work and experience. For this inspection the manager was required to complete an Annual Quality Assurance Assessment. The Commission had recently introduced this form. We have used information from this form to help us gather evidence about care outcomes for residents. What the service does well: The home offers residents a comfortable and well-maintained environment, together with a warm, hospitable and dignified atmosphere. Staff are friendly and well trained. Many comments were made by residents and relatives about their care and kindness: “One cannot improve on care that is already superb.” “It always feels like a resident’s home. People may come and go as they would in their own home but always cared for with kindness and respect.” “My relative really enjoys living at Broadlands. Staff have a sympathetic understanding of their clients and the care given is very good.” Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 6 Care Plans are detailed and correctly maintained. They are clearly laid out, easy to complete and quick to refer to. This ensures staff are always aware of the needs of residents as they change. Relatives are welcomed and involved in the day-to-day activity of the home. The Friends of Broadlands help to improve facilities and provide services to residents. Cooking and presentation of meals was seen to be of a very high standard with three /four choices of dishes available each day. Any comments by residents about the catering are actioned quickly. Staff induction and on-going training is comprehensive, well documented and encourages high standards. This ensures that residents are cared for by appropriately trained and up-to-date staff. The building has been carefully extended over the years and the rooms are well decorated, well furnished and with interesting views. The home is well regulated by the Trust which owns it, with comprehensive quality assurance measures to maintain and improve the home. This ensures that the home is run in the best interests of the residents. What has improved since the last inspection? The activities programme has improved with more people that arrange activities. There are different types of activity offered and this diversity offers the residents more choices. The conservatory, pink lounge and sun lounge have been refurnished. The garden adjacent to the Broad has been extensively developed to make it wheelchair accessible. The jetty and quay headings have been repaired and decked. Handrails have been installed to all areas of the garden. The fire alarm system has been updated. More rooms have been fitted with en-suite facilities. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The home does not provide an intermediate care service. Quality in this outcome area is excellent. Prospective residents can be assured that they will have full and attractively presented information on the home to enable them to decide if they wish to live there. Pre-admission assessments ensure that their needs are identified and that the home is able to meet them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose contained all the items of information required by the Regulations, such as the qualifications and experience of the manager and staff, a list of the facilities and services, the admission criteria and the complaints procedure. The Service Users’ Guide was also complete, and included a copy of the contract, called the accommodation and service agreement. It identified the room to be occupied by the resident and the fees to be charged. There was a notice in the foyer which also set out the fees for Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 10 each type of room. All the information was clear and easy to read and well laid out. The accommodation and service agreement confirmed that there would be a trial period of six weeks from the start of each new admission. The manager stated that shared rooms were only allocated to couples or two friends. If one of them died or had to move elsewhere, the room would be treated as a single room until a normal single room became vacant. This would then be offered to the remaining person. Conversely, we met a couple who had been able to move into the home by using two adjacent rooms, one as a bedroom, the other as a sitting room. When a double room had become vacant, the manager had offered it to them. They decided to move into it. It was in the process of being refurbished. They told us how good it was looking now that it was nearly finished. Pre-admission assessments were seen in the sample of care plans examined. The information was sufficient to form the basis for the initial care plan. Each assessment was signed by the new resident. One resident wrote: “I felt very apprehensive about moving into a residential care home, but having spent time here on respite breaks, I felt this home would be suitable for me. I feel very much at home here and feel I have made the right decision to stay here and be cared for.” Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is excellent. Residents can be assured that their views are taken into account, in terms of what their needs are, and how they want their care delivered, to ensure they receive the appropriate personal, health, and social care. Medication procedures ensure that residents are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We examined three care plans. All care plans followed the format of the provider which was based on work done partly at Broadlands. They were clearly laid out, with colour coding for alerting staff to changes in needs and to other specific dangers eg allergy to penicillin, instructions for keeping a resident safe when moving about in their room, identifying diabetic residents. The records were straightforward to complete and to read. There was a sheet for staff to sign that they had read the file to ensure that staff were up-to-date with residents’ changing needs and wishes. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 12 All plans we examined were signed by the resident. Care plans were reviewed monthly by the duty managers with space for residents’ comments. All plans identified by which name residents wished to be called. A member of staff said that most people agreed to be called by their first name. Files described the wishes of each person about the arrangements at the time of their death. Training in bereavement care had been arranged with the charity CRUSE to take place later in the year. All plans identified personal and health care needs, including such matters as the management of diabetes with instructions from the district nurse, clear instructions for staff in caring for an amputee, preferred daily routines such as getting up times, food preferences, and management of a resident with a catheter. Visits by medical professionals were recorded, such as the chiropodist, the speech therapist for swallowing difficulties after a stroke, the district nurses and GPs. One of the carers commented that if a resident was attending the physiotherapy clinic, the staff would always gather information from the clinic to ensure continuity of treatment. Three residents were currently in bed the majority or all of the time. They were cared for on hydraulic beds with electric air wave mattresses. The beds were provided by the home, who owned five of them. The special mattresses were supplied by the district nurses. Turning records were kept. We found them to be up-to-date. Fluid charts were also kept. None of these residents had developed pressure area problems. Instructions for staff on moving and handling these residents were clear and detailed. All plans contained personal risk assessments, several for risk of falls. Risk reduction strategies included half-hourly checks when the resident was in their room, moving furniture to give clear routes to the toilet, encouragement to use walking aids. Records showed that risk assessments were reviewed six monthly unless there was a reason to do so sooner. All residents who returned a survey form said that the home gave them the care and support they needed including medical support. A relative who spoke to us during our visit said that the staff had a sympathetic understanding of residents and their needs. A review of medication procedures and practices was undertaken. The temperature in the drug room was checked daily and recorded. It was consistently below the maximum recommended. The temperature of the drug fridge was also recorded. It was seen to be operating within a safe range. Controlled drugs (CD) were checked against the CD book. The stock of one drug for a resident was checked against the total listed as remaining. The remaining stock tallied with the records. The home’s policy required two signatures for CDs, including Temazepam. The Medicine Administration Record (MAR) sheets were examined. All administrations were signed for Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 13 appropriately. The assistant manager conducted a regular audit of the medication practice and showed us how this was recorded. We noted that the lunchtime medications were given out before the meal was served. This was good practice to allow residents to retain privacy and have an undisturbed meal. Nine residents were able to self-medicate. Each was given a month’s supply to be kept in a locked cupboard in their room. Risk assessments were in place for each person and we saw these in their care plans. These showed that the home promoted independence, and, for those residents assessed as being able, encouraged and supported them to manage their own medication. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is excellent. People living at the home can be assured that they will have opportunity to enjoy a range of activities, maintain links with the local community and friends and enjoy appetising meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an active ‘Friends of Broadlands’ group which was made up of relatives and which provided voluntary support and activities within the home. The Friends had recently organised and funded the rebuilding of the jetty and garden to provide a safe and wheelchair accessible route for residents’ enjoyment. Residents had requested this at their meetings. The lunch menu consisted of roast chicken, or stuffed peppers, salmon and asparagus flan and ham salad. The vegetables normally came from the home’s own garden. Tea was taken from 5.30pm, consisting on this day of kippers, or homemade pizza or sandwiches, with chocolate ice cream, cakes and yoghurt. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 15 Resident’s lunchtime was seen to be a calm and social occasion with staff interacting with residents in a supportive and unobtrusive manner. The room was light and laid out with a variety of table sizes. There were linen tablecloths and napkins. Staff brought vegetables to each table and served them as residents wanted. For those residents who chose not to eat in the dining room, their meal was taken to them and served on an individual tray with the meal conveyed with plate covers. Menus for the week were on the tables and were printed in large font for ease of reading. Special diets and menus were created for those who were diabetic and for one person with a coeliac disease to ensure that they could maintain their nutritional needs with choice of dishes. Puddings were displayed attractively in a chilled cabinet for residents to see prior to making their personal selection. Residents’ comments on the catering were generally very appreciative. All those who replied to the survey said that they always or usually liked the meals. A visitor told us that they had joined their relative for Christmas lunch in the home. From the week after our inspection, there would be three activities organisers covering the week between them, as another part-time organiser had been appointed. A chart on the noticeboard listed some of the activities happening that week. There was also a colourful leaflet listing activities for the month. Quizzes, Scrabble, flower arranging, darts, cards, manicures, exercise classes, bingo, music and skittles were some of the activities. We saw how the organisers kept an activities record which listed those who had participated, together with any feedback from them. The home owned a minibus which a volunteer driver took out on Wednesday afternoons either for group trips or for individual visits. We spoke to one resident who was using the residents’ computer. They had relatives abroad and found it was an excellent way of keeping in touch. The local church visited monthly for Holy Communion, and another church organised special services at Easter, Harvest Festival and Christmas. Comments from residents in the questionnaire about activities were mostly positive. Fourteen said that there was always or usually something they could take part in. Two said there was sometimes activities they could take part in. One wrote: “There are plenty of activities. I join in the ones I’m able to.” A resident told us that they could choose what time they got up and went to bed, and where to have breakfast, either in their room or in the dining room. They appreciated this flexibility and control over their daily routine. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. Residents can be assured that their views will be listened to, taken seriously and acted upon. There is a proper policy, procedure and training programme in place to give residents confidence that they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a Suggestions, Comments and Complaints policy, copies of which were displayed in reception. All required information was included, such as how a resident or relative could pursue a complaint if they were not satisfied with the home’s response. All the residents and relatives who replied to the surveys said that they knew how to complain and raise concerns. Several stressed that they had never had cause to do so. The complaints log showed that once again no formal complaints had been received by the home since the previous inspection. None had been received by the Commission. The home’s policy and procedure on the protection of vulnerable adults (POVA) was comprehensive, including the Suffolk Joint Agency protocol on reporting. Recruitment records showed that the appropriate checks were made before employment, and training records evidenced that staff received POVA training Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 17 at induction and annually, and during their NVQ studies. Two members of staff were able to give us examples of abuse, and were aware of the action to be taken. The home advertised on the notice boards an independent Advocacy Service although it appeared that no-one had used it. On occasions, members of the Friends of Broadlands committee had befriended residents who had no next of kin. No monies were kept by the home on behalf of any resident. They were either supported to look after their own monies, by the provision of lockable drawers in their rooms, or their finances were under the protection of relatives or legal representatives. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 18 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): 19,20,21,22,24,25,26, Quality in this outcome area is excellent. Residents can be assured that the home provides a comfortable and wellmaintained environment and that they are able to personalise their rooms should they wish to do so. Residents can be assured that the home is clean and odour free. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The standard of the environment at the Home, including its decor and fabric, remained high. The grounds were well maintained and overlooked the Broad. Access for residents had been improved by repairs to the jetty and new decking, Handrails and paths accessible for wheelchairs now enabled resident access to all parts of the grounds. One resident was seen to use their electric Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 19 wheelchair to move around the building, and to go outside in order to smoke in a designated covered area. Residents’ rooms were comfortably furnished. Many residents had brought in items of their own furniture, and had personalised their rooms in other ways. We spoke to one resident in their room who had items of their own furniture, plus their own bed and a recliner chair. This resident said they were very happy and very comfortable. There were pictures throughout the home depicting scenes of old Lowestoft. It has been noted under Choice of Home that only existing couples or friends were admitted to the shared rooms. A single vacancy in a shared room would not be filled until an alternative single room became available for that occupant. All areas of the home including WCs, bathrooms and a selection of resident’s own rooms were seen to be cleaned to a high standard and were pleasant smelling. Residents confirmed to us that the home was always fresh and clean. The home was currently upgrading seven rooms with en-suite facilities. Work was due to finish by the end of January. The work was causing some noise and disruption, but no resident mentioned to us that it was a problem for them. The home was about to start a major project to develop a seven-bedded extension in the cottage for high dependency residents. This would have an additional assisted bathroom and communal area. The provider would seek registration of these rooms by the Commission nearer the date of completion. We noted that there had been no instances of cross-infection in the home. Staff records showed that they received training in the control of infection. Broadlands Residential Home DS0000024346.V357661.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. Quality in this outcome area is good. Residents can be assured that they are cared for by well-trained staff, showing care and concern, and that they will be protected by the home’s policy on recruitment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five staff including a senior were rostered to be on duty throughout the daytime. A duty manager was also on duty. Three staff were on duty at night. This was appropriate for the current care needs of the residents. Staff and management were aware of the increasing dependency of some of the residents, with the planning of a high dependency unit a recognition of these changing needs. No agency staff were used by the home. Gaps in the rota were always filled from within using existing staff and relief staff. Thirteen residents, out of sixteen who filled in the survey, said that there were always sufficient staff available when they needed them. Two said this was usually the case. In the staff survey, five said there were always enough staff to meet the individual needs of residents, seventeen said this was usually the case and two said this was sometimes the case. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 21 The recruitment files for three new members of staff were examined. These contained evidence of identification as well as pre-employment protection checks. Application forms were complete with no unexplained gaps, and references were taken up. The files held information on the induction and other training which the person had completed since employment, together with certificates confirming attendance. These confirmed that staff who started before the full Criminal Records Bureau certificate had been received worked under supervision. The home followed the Common Induction Standards, and the new staff told us that they shadowed other staff until they were competent and legal to work on their own. Files also held records of supervision sessions which ensured that staff were able to discuss care practice issues and training needs regularly. All senior carers and fifteen carers had achieved NVQ Level 3 and four staff were studying for this level. Six staff had obtained NVQ Level 4. Therefore 69 of care staff were NVQ qualified. The assistant manager said that no staff study for Level 2, they went straight to Level 3. A carer wrote: “My NVQ3 gives me new ways of understanding residents’ needs and keeps me up-todate with new ways of working.” The manager showed us the current training action plan which covered each member of staff and was updated regularly to show when training had been done, and which courses were planned. Subjects covered included health and safety, moving and handling, first aid, fire, food hygiene, infection control, medication and abuse awareness. In addition three staff had attended a two day dementia care course. The manager said she had never had such a positive staff response to a course. She believed that it made staff step back and review what they were doing, not only for people with dementia, but for all residents. A member of staff said how thought provoking the training had been. They now realised how important understanding a person’s life history could be to giving them appropriate support. Observations of staff interacting with residents confirmed comments made by residents in the questionnaire. “Very good, caring and helpful management and staff.” “The staff are always pleasant and approachable. I am lucky to be in such a caring place.” All residents who replied to the survey said that staff always listened and acted on what residents said. Broadlands Residential Home DS0000024346.V357661.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): 31,32,33,35,36,37,38. Quality in this outcome area is excellent. Residents can be assured that the home will be managed well in an atmosphere of openness and respect, their views will be sought and that there are systems in place to ensure their safety and well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager was very experienced in the care of older people. She had been the registered manager at the home since 1999, and also fulfilled a wider role for the Trust with their local homes. Under her were four duty managers, one of whom would be on duty at all times in the home. The manager had an NVQ Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 23 Level 5 in Management and a Level 4 in Care. All duty managers had NVQ Level 4. Residents’ meetings were advertised and held regularly. They took the form of a table by table discussion, where residents were in small groups around tables and staff moved around asking them for any issues or comments. It was felt that this was a better way of encouraging residents to express their opinions. Examples of topics raised in the notes included menu items, cooking methods, activities and the garden access. All residents who completed the survey said that the staff listened and acted on they said. Staff meetings for care staff were held every three months, meetings with Senior Carers every two months, and managers met every month. Staff told us that residents were consulted on any changes and were encouraged to voice opinions or concerns at regular meetings. “The manager always makes herself available to listen to any concerns.” All staff received formal supervision sessions every two months. Staff were allocated between the senior carers and the manager. The records of these sessions were seen on file, together with an annual schedule of dates to check that it was up-to-date. Annual appraisals also took place. The provider had a Quality Assurance manual which contained the home’s policies and procedures. Staff signed to confirm that they had read them. The quality manual included evidence of a number of quality audits, such as medication, health and safety, and housekeeping, as well as records of weekly hot water checks and monthly checks on commodes and wheeled equipment. The fire log contained records of fire training, equipment tests and alarm tests and was up-to-date. The Fire Risk Assessment had been compiled by a professional fire assessor in June 2006 and had been reviewed in June 2007. Fire training was organised by one of the senior supervisors. She inspected fire extinguishers and tested emergency lighting weekly together with the testing of the fire alarm. These checks were all documented. The home was inspected by the local Environmental Health Officer in November 2007. Very high standards were observed in all food rooms and practices. One recommendation had been made regarding the re-labelling of food. This had been actioned. We examined the accident book. There were no unusual incidents or any pattern of incidents for any particular resident. There was a helpful analysis of accidents and incidents by name. We examined the analysis of falls. One resident had had several falls which the GP had attributed to the effect of a recent surgical operation. They had been referred for further investigation. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 24 A representative of the provider visited the home monthly and produced a report of their visit. We saw that these were up-to-date and met the legal requirement. The home’s insurance certificate was up-to-date and displayed in reception. As was the current Certificate of Registration issued by the Commission. We saw that the home’s records were up-to-date, accurate and secure, with evidence of residents contributing to their care records. Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 25 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 4 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 4 3 X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 4 3 Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broadlands Residential Home DS0000024346.V357661.R01.S.doc Version 5.2 Page 28 - 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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