Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 18/11/05 for Broadleigh

Also see our care home review for Broadleigh for more information

This inspection was carried out on 18th November 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides personal and nursing care for older people. People who live there said care staff are lovely, polite and kind, and "everything you want to be done, they do. I couldn`t ask for more". One person said the home is brilliant. Care staff in the home try hard to make sure people have the opportunity to choose what they do everyday, and when and how they do it. The home is decorated in a homely way and provides a comfortable and friendly environment for people who live there.

What has improved since the last inspection?

The home was told they had to improve two aspects of assessment and care recording during the last inspection, which they have done. An assessment of people who want to live there is completed before they go into the home, and assessments from hospitals and/or social service departments are also asked for. This makes sure there is enough information for the home to say it can look after that person properly. Plans that tell care staff how to look after people so that their needs are met properly are reviewed at least every month. This makes sure that any changes in the way people are cared for is recorded and the care that is given is correct.

What the care home could do better:

There are three issues arising from this inspection that the home must improve on. Most importantly are the checks that must be carried out for all new staff members working at the home. References must be asked for and received, and periods between jobs or studying must be accounted for. New staff members must not be employed before checks against the Protection of Vulnerable Adults register have been returned and are satisfactory. These are all done to protect vulnerable people and must be completed before a new staff member works at the home. Although the home is comfortable and nicely decorated, there are pipes leading from radiators and a radiator in a toilet that are not covered and hot to touch. This means the home is not completely safe and steps must be taken to makes sure people who live at the home are safe. Checks of fire equipment are required to make sure it can be used in the event of a fire. Not all of these were available during the inspection or produced since and therefore the home cannot show the checks have been completed.

CARE HOMES FOR OLDER PEOPLE Broadleigh 213 Broadway Peterborough PE1 4DS Lead Inspector Lesley Richardson Unannounced Inspection 18th November 2005 12:00 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 Broadleigh DS0000024317.V260426.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. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadleigh Address 213 Broadway Peterborough PE1 4DS 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) 01733 562328 01733 555841 Willowgable Limited Mrs Shamshad Bano Marjara Care Home 32 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (32), of places Terminally ill over 65 years of age (32) Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Broadleigh is a large converted and extended house, situated on a main road near the centre of Peterborough. It is owned by Willowgable Ltd and provides care and support, including nursing care for up to 32 residents over the age of 65 years. The home has 24 single rooms and 4 double rooms; all rooms have en suite facilities. Resident accommodation is on two floors, the upper floor being accessible by stairs or lift. There is a large communal area available to service users on the lower floor, with smaller areas on the lower floor and upper floors. Service users have access to the gardens surrounding the home, which are tidy and attractive. The home is situated within 1 mile walk of the centre of Peterborough, where there is a wide range of shops, pubs and public amenities. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 3½ hours and was carried out as an unannounced inspection on 18th November 2005. It was the second inspection of this home for the 2005-2006 year. Two hours were spent examining records and documents and one and a half hours were spent with service users and staff. A tour of the building was also undertaken during this time. The manager was present during the inspection. Four people who were living at the home and three of the staff on duty were spoken to during the inspection. Not all service users were able to express their views. What the service does well: What has improved since the last inspection? The home was told they had to improve two aspects of assessment and care recording during the last inspection, which they have done. An assessment of people who want to live there is completed before they go into the home, and assessments from hospitals and/or social service departments are also asked for. This makes sure there is enough information for the home to say it can look after that person properly. Plans that tell care staff how to look after people so that their needs are met properly are reviewed at least every month. This makes sure that any changes in the way people are cared for is recorded and the care that is given is correct. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 6 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. Broadleigh DS0000024317.V260426.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 Broadleigh DS0000024317.V260426.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): 3 Pre-admission assessments of prospective service users ensures the home is able to meet service users needs. EVIDENCE: Pre-admission assessments are completed by the manager to ensure new service users needs are properly assessed and planned for. Assessments of need are also obtained from healthcare professionals and social service departments. This gathers as much information as possible about each person before they enter the home and ensures their needs can be met. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10 The home has systems in place to ensure care needs are met through planning. EVIDENCE: Care plans are available for each service user to ensure personal and health care needs are met in the most appropriate way. Needs identified through risk assessments and changes in service users abilities are included in care plans. Although one service user with mobility problems did not have a plan to show how this need was to be met during the day, information about how to ensure safety and reduce risk was contained in other plans. Plans are reviewed on a monthly basis to ensure changes in need and the most appropriate way to meet them are recorded. Service users said they liked the home and staff members are always obliging and helpful. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are enabled to make choices in their daily lives. EVIDENCE: Service users said they are able to get up and go to bed when they wish, and have a choice of meals each day. Care staff were polite and asked service users what they would like rather than suggesting or telling people what they would like them to do. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed on this occasion. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 The standard of the environment within this home is good, providing service users with an attractive and homely place to live. There was one area of concern which put service users at risk of harm and did not provide safe surroundings in which to live. EVIDENCE: The home is well decorated and maintained, and all areas are accessible and safe for people who live there, with large open communal spaces. It was clean, tidy and all areas were free from offensive odours. Most radiators are covered to ensure safety but pipe work from radiators and one radiator in a toilet were not covered and were hot to touch. These need to be covered to ensure service users are safe at all times. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 13 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 The procedures for the recruitment of staff must improve to offer protection to people living at the home. EVIDENCE: The files of two recently employed staff members shows the home undertakes most of the necessary recruitment checks to ensure the protection of service users. There were three areas of concern that the home must improve to ensure new staff are safe to work with vulnerable adults. • Enhanced Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (PoVA) checks are applied for but there was no record that PoVA checks had been returned prior to staff members starting work at the home. • The employment history for one staff member was in months and years, the other staff member had no employment history but gave an education history, which was also in months and years only. Gaps in employment and between finishing studying and starting work had not been explored by the home. • References that had been written several months before these staff members had applied to work at the home had been accepted. No further checks had been made to verify the accuracy of the references. Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 14 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): 35, 37 and 38 Improvement is needed to ensure checks and records are kept to a standard that ensures service users health and safety. EVIDENCE: Records are kept for all money held on service users behalf, credits and debits, together with receipts are documented and the person performing the transaction signs to show who is responsible. Records were seen for 10 service users, which were in order. The home does not have appointeeship status for any service users finances. Checks are required to ensure the health and safety of service users and these must be recorded. Records were seen for fire safety, hot water temperatures, security alarms, plumbing and heating, and gas safety. These were all recorded as acceptable although records were not available for September and October’s emergency lighting and fire alarm testing. A copy of the emergency Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 15 light testing checks for that period have been forwarded to the Commission for Social Care Inspection since the inspection. Fire safety check records must be kept up to date and must be available for inspection. Portable appliance testing and equipment (lift and hoist maintenance) check records were not available in the home during the inspection. One staff member is responsible for ensuring the health and safety checks are carried out and maintaining records. Broadleigh DS0000024317.V260426.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X 2 3 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X 2 2 Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13(4)(a) Requirement The registered person must ensure that all parts of the home to which service users have access are free from hazards to their safety. All radiators and pipe work must either be covered or have guaranteed low temperatures. The registered person must not employ a person to work at the care home unless he has obtained the information and documents specified in Schedule 2. He is satisfied as to the authenticity of the references. The registered person must maintain in the care home the records specified in Schedule 4. A record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the care home must be kept. The registered person must make adequate arrangements for testing fire equipment. Timescale for action 15/01/06 2 OP29 19(1)(b) (i), (c) 31/12/05 3 OP37 17(2) 31/12/05 4 OP38 23(4)(c) (v) 15/01/06 Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 18 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 Broadleigh DS0000024317.V260426.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Broadleigh DS0000024317.V260426.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!