Inspection on 29/01/07 for Broadleigh

This inspection was carried out on 29th January 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broadleigh 09/10/07

Broadleigh 18/11/05

Broadleigh 20/07/05

Broadleigh 30/11/04

Broadleigh 06/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Broadleigh 213 Broadway Peterborough PE1 4DS Lead Inspector Lesley Richardson Key Unannounced Inspection 3:30 29th January 2007 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.V310511.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. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 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 amar@broadleighcare.co.uk 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.V310511.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 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. Fees for the home range between £350.00 and £470.00 per week. The most recent CSCI inspection report is available for service users and other interested people to read in the activities and information area in the main lounge room. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and 15 minutes and was carried out as an unannounced inspection on 29th January and 6th February 2007. It was the key inspection for this home for the 2006-2007 year and was completed by the lead inspector. Four hours were spent with staff members, service users and undertaking a tour of the home. The inspection was conducted with the manager present. The home was asked to complete and return a pre-inspection questionnaire to the Commission before the inspection took place, and give out questionnaires to people who live at the home and visitors to the home. 27 questionnaires were returned. Information from these questionnaires and a random inspection that took place in July 2006 goes into this report along with the information found at this inspection. Three requirements and five recommendations have been made as a result of this inspection. One of these requirements has been carried over from the last inspection, as it has not been met. What the service does well: The home provides personal and nursing care to a good standard and people living at the home clearly like living there. Everyone who answered the questionnaire and spoke with the inspector said they get the care they need and staff are available when they need them. Relatives and visitors to the home also felt the same way and comments include, “I feel lucky to have found such an excellent home for my wife”, “it is an excellent nursing home … with very good staff support”, “my mother is looked after in the best possible way and is cared for in exemplary fashion”, and “the owners and staff at Broadleigh are very dedicated to their work – it is an extremely well run and managed care home”. Visitors are made welcome at the home and they can visit in private if they want to. There is a wide range of activities available in the home and staff work hard to try to provide something for everyone. Although, some comments from people who live at the home and relatives shows that activities are not always suitable for people who cannot move and get around easily. Meals are generally of a good standard, and residents all said they like the food that is provided. They can always get something different to eat if they don’t like the main meal. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 6 There is a complaints policy in the home and most people know how to make a complaint if they need to, although there have been no complaints in the last year. Residents all said they know who to speak to if they are unhappy about something. The home is a safe and pleasant place to live; it is nicely decorated and residents have different areas where they can sit and relax. Staff members have enough training to make sure they have the skills to properly care for people who live at the home. Non-nursing staff are encouraged to complete national vocational qualifications and this means that over 50 of the care staff at the home have this qualification. The manager is qualified for the job; she is registered as a nurse with the Nursing and Midwifery Council and keeps up to date with new training and updates her existing knowledge. A survey is completed twice a year so that staff can obtain the views and opinions of people living at the home and other people who visit the home. A report of the results then shows where people think the home can improve and what they already like or don’t like about it. This means the home is run with the residents’ interests in mind. Records that show health and safety checks and how the home manages residents’ money are kept accurately. This means residents welfare is promoted and protected. What has improved since the last inspection? What they could do better: The home must obtain all the checks that are required before a person starts working at the home. A Protection of Vulnerable Adults (PoVA) check must be issued before a person can start working at the home, 2 satisfactory references must be obtained and the home must ask any prospective staff member about gaps in employment. This must be done to make sure people who live at the home are in safe hands. The home had not completed these checks properly at the random inspection in July 2006 and it was found they had not completed these checks properly at the last key inspection in November 2005 either. This is not acceptable and must improve. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 7 Care records are generally detailed and well written; they give staff members a good idea of what they have to do to care for each person properly. However, it is sometimes difficult to find specific information, as it isn’t always recorded in the most obvious place. Risk assessments are completed for nearly all risks, although one person was being restrained in a chair but the care records did not show why this was the most appropriate way to keep him safe and there were not records to show how often this was being done. Most medication practice was good, but there are short periods when the medication trolley is left unattended and the medication is available to anyone passing. This is not good practice and puts people at risk. 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.V310511.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 Broadleigh DS0000024317.V310511.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. There are systems in place for service users needs to be assessed before being admitted to the home, thereby ensuring the home will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Pre-admission assessments are completed by the home and obtained from health and social care professionals in the community or acute care settings. These assessments give the home information about prospective service users and allow them to make a judgement about whether the home and staff will be able to provide appropriate care for that person. The home does not provide accommodation for intermediate care or rehabilitation needs. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 10 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, 8, 9 and 10 Quality in this outcome area is adequate. Improvement is required in the systems for assessing risk to ensure service users rights are not infringed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual care plans are written for service users. These are generally detailed and contain enough information for staff to care for service users properly. Some specific details are recorded on long term care plans, such as the best way to assist a person or specific dietary information. However, this information is not always transferred to specific plans. For example, one person’s nutrition/dietary plan did not include the best way for that person to eat, which was with a teaspoon, or the need for a high protein and carbohydrate diet. Another person’s plan for managing challenging behaviour gave advice but no direction, for example, how to divert attention or what to divert attention to. Risk assessments are also contained in the care records and these alert staff when the level of risk for a particular activity increases. These are completed and reviewed regularly. However, guidance for staff about what to do when Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 11 risk levels reach a particular point were not available in care plans. During a tour of the building one person was seated in an armchair in his room with a table locked onto the chair in front of him, effectively ensuring he was restrained. A staff member said this was done to stop him getting up and falling over. There was no risk assessment to show this was the only means of maintaining this person’s welfare or care records detailing the restraint and why it was required. Service users plans contain information about their health needs and evidence that they see a wide range of health professionals regularly. The home has policies and procedures in place for medication. Medication storage and administration records were checked and found to be satisfactory, including appropriate details for medication not given. The evening medication round began at 4.10pm, which does not give an adequate time between the lunch medication round for those people requiring medication 4 times a day. The medication trolley is taken to an area where and medication is administered to each person individually. However, medication is not returned to the trolley and the trolley is not locked when the registered nurse turns her back or enters a service users room to give the medication. Service users and relatives said staff are polite, they knock before entering rooms and will do anything to help. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 12 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 and 15 Quality in this outcome area is good. Activities in the home provide entertainment, stimulation and variety for residents and they are able to choose how they spend their day. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 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 short trips out of the home. There is a range of games, planned entertainment and seasonal events for service users, which is clearly advertised on a notice board in the main lounge area. A survey is sent to service users two to three times a year so that the home is able to continually assess what they would like to do with their time. Just over half the service users answering the CSCI survey said there are activities for them to join in. Although, other comments from the survey said there was limited activity for people with restricted mobility. Family and visitors are made to feel welcome at the home. All the relatives and visitors who responded to the CSCI questionnaire also said they are able to visit in private if they wish. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 13 Meals are prepared at another home a short distance away and served from a heated trolley. Service users who wish to can sit in the dining area for their meals, where tables are set with place mats, coasters, napkins and condiments. Service users said they enjoy the meals, and one person said although she never asks for an alternative, one would be available if she requested. Preparations were being made for the evening meal just after 4pm on the first day of the inspection, which is not long after lunch but leaves rather a long time until breakfast the next day. Snacks are available in the evening if service users wish to eat again. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is adequate. The home had a satisfactory complaints system with evidence that service users were able to confidently raise concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedures in place to guide staff in dealing with complaints and for the protection of vulnerable adults. Details of how to complain are contained in the home’s Statement of Purpose, the Service Users’ Guide and the procedure is also displayed in the home. Information provided before the inspection shows the home has received only one complaint in the last 12 months. All the relatives responding to the CSCI questionnaire said they are aware of the complaints procedure and all but one service user said they know how to make a complaint, although everyone said they would know who to speak to if they were unhappy. There has been one adult protection incident since the last key inspection, which was looked at during a random inspection in July 2006. A referral to the adult protection team was not made by the home; this was made by another care facility following concerns they had. The staff member involved was dismissed from Broadleigh and referrals made to the Nursing and Midwifery Council and PoVA lists. Staff files seen indicated 3 staff members who had started working at the home in August and September 2006 had not received training in this area. However, two staff members were scheduled to attend Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 15 training given by the local adult protection team in the 2 weeks following the inspection and the manager said other training has been given. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 22 and 26 Quality in this outcome area is good. The standard of the environment within this home is good, providing service users with an attractive and homely place to live. This judgement has been made using available evidence including a visit to this service. 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. Radiators are covered to ensure safety, work to cover pipe work from one hot water outlet in a toilet was completed during the inspection. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30 Quality in this outcome area is adequate. Systems for the recruitment and vetting of new staff members must improve to make sure service users are safe. Service users are cared for by trained and competent staff, ensuring their needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels at the home are adequate. There were four care staff and one registered nurse on duty during the inspection. Information provided before the inspection shows levels of staff during the day are acceptable, but there is only 1 registered nurse and 1 member of care staff on duty at night. Although this is generally felt to be quite a high ratio of service users to staff, service users said staff are available when needed and relatives also said they felt staffing levels are adequate. Staff files were examined at the random inspection in July 2006 and a requirement made regarding the need to obtain checks, documentation and information detailed in Schedule 3 of the Care Homes Regulations 2001. Staff files for 3 people who started working at the home between August and September 2006 were examined during this inspection. PoVA 1st checks had not been obtained for two staff members who started work before the CRB declaration was issued. References for one person were satisfactory, although they were from people in comparable positions to the applicant and not from a line manager or person in a position to give an objective view. References for Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 18 the other two staff members are photocopies, not the original references and had been obtained through a third party. One of these people had only one reference and the other had a reference from a person whose name did not appear on the application form. The employment history in one person’s application form was in months and years only, and another person had a gap of 3 months. There was no explanation in these staff members’ files regarding the references or exploring gaps in employment history. The requirement from the inspection July 2006 has not been met. Training records show that staff have received training in all mandatory areas as well as training in a range of other areas. This includes areas specific to service users individual needs, such as dementia, and in the use of specific equipment, such as syringe drivers. Information provided before the inspection shows 75 of care staff have a National Vocational Qualification at level 2 or above. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 and 38 Quality in this outcome area is excellent. There are good management and administration systems at the home, and the quality assurance system ensures the home is run in the best interests of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a nurse registered with the Nursing and Midwifery Council and has the relevant experience to run a care home for older people. She keeps up to date with current good practice and attends training in line with service users needs. The activities co-ordinator and staff organise the home’s quality assurance programme. A twice yearly questionnaire is given or sent to service users, their relatives or representatives, and visiting professionals. The responses are collated and a short report is written that identifies the positive comments Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 20 and any issues that are raised. An action plan is produced, which looks at ways the home can improve any areas that have been identified in the questionnaire as not meeting service users expectations. Records are kept to show the transactions made into and out of money, kept by the home on behalf of service users. These are accurate and receipts are obtained for debits. Information provided before the inspection shows health and safety maintenance checks are completed at the required intervals. Records and equipment seen during the inspection show that fire safety checks and maintenance is completed, and hot water checks are also completed even though all taps have mixer valves that maintain water temperatures at a satisfactory level. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 21 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 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 13(7), (8) Timescale for action Records must show why restraint 15/03/07 is the only practicable means to secure a resident’s welfare. Each time restraint is used the method of restraint and circumstances leading to its use must be recorded. Medicines must not be left 15/03/07 unattended. 15/03/07 A person must not be employed at the home unless: • A satisfactory PoVA check has been issued. • A satisfactory written explanation of any gaps in employment has been obtained. • Two satisfactory written references have been obtained, including a reference relating to the person’s last employment involving work with children or vulnerable adults. The registered person must be satisfied as to the authenticity of the references. (Timescale of 31/12/05 and 21/07/06 not met.) DS0000024317.V310511.R01.S.doc Version 5.2 Page 23 Requirement 2 3 OP9 OP29 13(2) 19(1)(b) (i), (c) Broadleigh 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 2 4 5 Refer to Standard OP7 OP7 OP15 OP18 Good Practice Recommendations Care plans should give specific examples regarding how care is to be given, e.g. when diversionary tactics are required, what works for that particular service user. Risk assessments should include recommended guidance for staff to follow if scores reach particular levels. The timings of meals should be reviewed to ensure that there is not too long a gap between when food is readily available for residents. All staff should undertake training in the protection of vulnerable adults, which should include local guidelines. Broadleigh DS0000024317.V310511.R01.S.doc Version 5.2 Page 24 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.V310511.R01.S.doc Version 5.2 Page 25 - 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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