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Inspection on 20/07/05 for Broadleigh

Also see our care home review for Broadleigh for more information

This inspection was carried out on 20th July 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 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 views and opinions of people living at the home are sought at least twice a year, which helps the home run with their best interests in mind. People who visit the home, as visitors or health care professionals, are also asked their opinion of the home and whether improvements can be made. One person living at the home said she has plenty of opportunities to tell a staff member if she is not happy with something and this resolves issues before they become a problem. Staff members are given basic training when they first start at the home and have additional training specific to the needs of people living at the home after that. All staff members are included in this training, although the trained nurses at the home are given extra training for procedures they have to perform. The home provides a friendly, family run environment that is clean and nicely decorated for people to live in.

What has improved since the last inspection?

The recording of medication administration has improved and records now show clearly whether a person has had a medication or the reason they have not had it. The environment has been improved to make it safer for people living there. Pipes from radiators have been covered, which reduces the risk of burns occurring if people lean or fall against them, and all doors are kept open with a self-closing device. This makes sure that, if there was a fire, people living at the home would have the best chance of getting out of the home and the fire would be contained.

What the care home could do better:

SU needs must be fully assessed before they are admitted to the home. This is so the home can show staff are able to meet the care needs of those people, as they must not admit people to the home if they cannot guarantee this. Care records must also be reviewed, and this should be done on a regular basis. Some care records did show very good information about how people should be looked after, but one file did not show if anything about that person had changed for some months. Care records must show whether there has been a change or not.

CARE HOMES FOR OLDER PEOPLE Broadleigh 213 Broadway Peterborough PE1 4DS Lead Inspector Lesley Richardson Unannounced 20 July 2005 @ 10:00 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 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 I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broadleigh Address 213 Broadway Peterborough PE1 4DS Telephone number Fax number Email 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 Willowgate Limited Mrs Shamshad Bano Marjara Care Home with Nursing 32 Category(ies) of Dementia - over 65 years of age (3), (DE(E)), registration, with number Old age, not falling within any other category of places (32), (OP), Terminally ill over 65 years of age (32), (TI) Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30th November 2004 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 I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5½ hours and was carried out as an unannounced inspection on 20th July 2005. Two and a half hours were spent examining records and documents and three hours were spent looking around the building and spending time with service users and staff. Six people who live at the home and six of the staff on duty were spoken to during the inspection. What the service does well: What has improved since the last inspection? The recording of medication administration has improved and records now show clearly whether a person has had a medication or the reason they have not had it. The environment has been improved to make it safer for people living there. Pipes from radiators have been covered, which reduces the risk of burns occurring if people lean or fall against them, and all doors are kept open with a self-closing device. This makes sure that, if there was a fire, people living at the home would have the best chance of getting out of the home and the fire would be contained. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 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 I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 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 standard(s) 3 There is evidence that the home does not fully assess all of its service users prior to admission to the home, therefore it cannot guarantee to be able to meet their needs. EVIDENCE: None of the three service user files seen contained a pre-admission assessment. Only one of these service users had been admitted long enough ago to archive this information. The manager said one of the other service users had not been assessed before moving to the home at the request of family and the other service user had been assessed, although the assessment was not available. Information available in the assessments completed after service users entered the home identified specialised needs that the home may not have been able to meet. This was discussed with the manager during the inspection. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 Systems are in place to ensure service users’ health and social care needs are met. Reviews are not completed on all service users to ensure changes in care needs can be met. EVIDENCE: Three service user files were looked at during the inspection. Two of the files contained care plans that were detailed and gave good descriptive actions on how each identified need should be met. Needs identified as high risk on risk assessment had clear instructions on how to manage care, thereby reducing the risk of worsening condition. Each element in these two plans had been reviewed and updated on a monthly basis. The care plan in the third file had not been reviewed on a monthly basis, many elements to the plan had not been reviewed for 4 months and some had not been reviewed at all since they had been written in February 2005. This does not give staff any guidance on how to meet new needs, and does not ensure continued safety for service users. This was discussed with the manager during the inspection. Service users have access to trained nurses 24 hours a day at the home. Care records also show access to GPs, CPNs (community psychiatric nurses), optician and chiropody healthcare professionals. Trained nursing staff at the Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 10 home administer medication and have undertake medication training since the last inspection. There has been an improvement in the medication administration records, which showed accurate recording for medication administration or medication not given. The home has recently changed its supplying pharmacist, and this new service provides a review of service users’ medications every 3 months and a more organised system. Staff said this service was much easier to work with. All service users said they were able to choose when they got up and went to bed, what they did during the day and whether they wanted to participate in activities. One service user said she didn’t participate in any activities and stayed in her room during the day, but this was her choice and she enjoyed the privacy this gave her. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 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 standard(s) 12, 14 and 15 Social activities in the home provide stimulation and interest for people living there, and the staff ensure service users have a choice in their daily lives. EVIDENCE: The inspector joined two service users for lunch. The meal consisted of roast turkey, roast and mashed potatoes, brussel sprouts and carrots. There was a choice of two desserts and a soup starter. Although there was no choice in main meal, service users said alternative meals are available if something is not liked. The meal was service in a pleasant environment in the dining room with service users who were able to and wished to eat there. Service users who require assistance with eating their meal are helped with this at the same time. The home employs a part time activities co-ordinator, who works with a small committee of staff to arrange things for service users to participate in and trips out of the home. Staff said it was planned that service users would also be included in the committee in the near future. A survey is sent to service users two to three times a year so that the home is able to continually assess what service users would like to do with their time. Service users said they enjoyed the activities planned, and especially enjoyed a trip to the seaside earlier in the year, but did feel there wasn’t a lot to do during the day. One service user Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 12 said she had been asked about her social interests during conversations with staff members, although this was not reflected in service user files seen. Care workers were polite to service users during the inspection and were able to give good examples of how they would ensure a service user’s privacy and dignity. Service users said the care staff are polite, always do the things asked of them and are very caring. They also said they were able to go to bed and get up when they wanted and were given choice in their daily lives. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 Systems are in place to ensure service users are able to raise concerns and have these listened to effectively. EVIDENCE: Service users said they would be happy to raise concerns with someone at the home, although staff always asks them if they are happy and they have plenty of opportunities to talk to someone before anything becomes a big problem. One service user said she feels very safe at the home and they provide everything she and other service users want. The home has policies for complaints and for the protection of service users, which would guide staff in dealing with any complaint or allegation made and assist service users or visitors to the home in making a complaint. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 14 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 standard(s) 19 and 26 The standard of the environment within this home is good, providing service users with an attractive and homely place to live. EVIDENCE: The home is situated in a leafy suburban area of Peterborough and appears similar to other houses in the road. There is an extension to the rear of the property that is easily accessible from the main dining and lounge area. All areas in the home are nicely decorated and well maintained, and smaller areas especially having a domestic, homely feel about them. The laundry is sited away from the kitchen and dining areas, ensuring the risk of cross infection is kept to a minimum. On the day of the inspection the home was clean, with no offensive odours apart from one area at the end of an upstairs corridor. The manager said this had been caused by a leak in one service users bathroom, although this was being addressed by a plumber and new flooring was being laid. Most radiator pipes have been covered since the last inspection, although on the underneath of some of the radiators a short Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 15 amount of exposed pipe work remains. However, the pipes remained cold after the radiator had been turned on. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 Staffing numbers and staff training opportunities were sufficient to meet the needs of service users. EVIDENCE: On the day of inspection the home had 32 service users resident, with four care staff and one trained member of staff on duty. This adequately covers the needs of service users, using the Residential Forum tool. Although staff files were not looked at during this inspection, staff said they had all the required mandatory training and other training specific to the service user group at the home. Induction training was given and new staff members were supervised for the first 2 or 3 weeks of their employment. Service users also said they felt staff members were adequately trained and they all knew how to do everything. The trained member of nursing staff on duty said she also had training in invasive procedures, such as venepuncture and male catheterisation. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The home’s policy encourages service user and staff participation, thereby enabling the home to be run in the best interests of the service users. EVIDENCE: The activities co-ordinator completes a service user, relative, and stakeholder survey every 4 to 6 months to ensure the views of all parties relevant to the home are heard. Each survey is analysed and an action plan drawn up from the results, enabling individual preferences and ideas to be discussed. Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x x Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 19 NO 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 3 Regulation 14(1)(a), (b) Requirement The registered person must not provide accommodation to a service user at the care home unless the needs of the service user have been assessed, and a copy of the assessment has been obtained. The service user plan must be kept under review. Timescale for action 31st July 2005 2. 7 15(2)(b) 31st July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Broadleigh I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 I53 I03 24317 BROADLEIGH V235377 200705 STAGE 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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