Inspection on 04/01/07 for Broadoak Lodge

This inspection was carried out on 4th January 2007.

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.

Other inspections for this house

Broadoak Lodge 05/10/07

Broadoak Lodge 05/12/05

Broadoak Lodge 04/08/05

Broadoak Lodge 11/11/04

Broadoak Lodge 26/07/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Broadoak Lodge Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector Mick Walklin Key Unannounced Inspection 4th January 2007 10:30 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 Broadoak Lodge DS0000001816.V323849.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. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoak Lodge Address Sandy Lane Melton Mowbray Leicestershire LE13 0AN 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) 01664 481120 01664 481120 Mr John Nunn Mrs Barbara Elsie Nunn Mrs Christine Mary Carne Care Home 27 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number disorder, excluding learning disability or of places dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (27), Physical disability (4), Physical disability over 65 years of age (4) Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one may be admitted into the home in categories PD or PD E when there are already 4 persons of that category accommodated in the home. Service User Numbers. No person to be admitted into the home in categories MD, MD(E) or DE(E) when 5 persons in total of these categories or combined categories are already accommodated in the home. No one under the age of 55 years can be admitted to the home. 3. Date of last inspection 5th December 2005 Brief Description of the Service: Broadoak Lodge is one of fifteen homes owned by Mr and Mrs Nunn. The Registered Providers set up the Broadoak Group of Care Homes in 1986. Mr and Mrs Nunn have 17 years experience in providing nursing and residential care. The home provides care for 27 older people with a range of mental health, dementia, and physical disability. The home is set on one level around a courtyard. There is a paved area with seating and shrubbery within. The home is well maintained and furnished to a good standard. There are bar facilities within the home and two lounges. All rooms offer en-suite facilities. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information available to the inspector regarding the service history of Broadoak Lodge, and through undertaking a visit to the home. The fieldwork visit took place over 7 hours. The manager was not present during the inspection. The main method of inspection used was called case tracking which involved selecting three service users and tracking the support they receive through the checking of their records, discussion with the care staff and observation of care practices. A tour of the building was undertaken with a member of staff. Documents connected with the running of the care home were also inspected. Seven ‘Have Your Say’ leaflets were received from service users. The manager had completed a pre-inspection questionnaire in June 2006. This provided information that the range of fees charged is £425 per week. What the service does well: What has improved since the last inspection? Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 6 The complaints procedure has now been amended to include the contact details of the commission. 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. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 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 Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good pre-admission procedures, ensuring that prospective service users needs are fully assessed prior to admission. EVIDENCE: One service user case tracked had been admitted in June 2006. They had been admitted directly from hospital, and a copy of the discharge summary and social services care plan had been provided to the home for information. A detailed assessment had been completed on the day of admission. Because of the circumstances of the admission, it had not been possible for the service user to visit prior to admission, but during the inspection, the relatives of a prospective new admission were being shown around. Other service users had Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 9 a detailed pre-admission assessment, covering a wide range of topics. All admissions to the home are for a one-month trial period. Broadoak Lodge DS0000001816.V323849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are of a good standard, and there are good relationships with local health providers to ensure that service users health needs are met. Medication procedures are robust to ensure safety. Staff treat service users with respect. EVIDENCE: Care plans are well organised, and provide staff with good information about service users support needs. Assessments outline areas of independence, as well as areas of need, and care plans reflect assessed needs. All care plans inspected had evidence that the service user or their representative had been consulted, and one relative said that she had been fully consulted about her relative’s care plan, and had been given a copy. Care plans are reviewed on a monthly basis, and daily records are fully completed. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 11 Staff said that they have an excellent relationship with the local GP surgery. A record of all medical interventions is kept in the service users care plan. Opticians, dentists, chiropodists, and audiologists visit the home regularly, and service users can also use community facilities. Other services, such as psychiatric nursing support is available by referral. One member of staff commented, “We have a fantastic relationship with the district nurses”. No service users currently self-medicate. The home uses a pre-dispensed system, and medication is administered by senior staff, who have received training from the pharmacist. Medication storage, administration and stocktaking arrangements are satisfactory. There was an excellent rapport between staff and service users, and service users and their relatives praised the attitude and kindness of the staff. One service user said, “They are good girls – very kind and caring”. Another said, “It’s not just the building that makes you feel good – it’s the staff”. Staff were observed to always explain the service users what they were doing, when providing care and support. They provided reassurance if service users became worried, or confused. They ensured privacy when carrying out personal care, by always knocked on bedroom doors before entering. Broadoak Lodge DS0000001816.V323849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are a range of activities to stimulate service users. There is good contact with families, and service users exercise choice and control over their lives, as far as they are able. Catering arrangements reflect individual choices. EVIDENCE: Service users hobbies and interests are documented in care plans. A large blackboard in the living room gives details of activities planned for the week. A different activity is planned for each day of the week, and activities for this week included a new years party, a pantomime, bingo and lottery party. One service user said, “We do quite a lot – I enjoy bingo and the lottery”. However, another service user said, “We were meant to do ‘I-Spy’ today, but that hasn’t happened. We used to have a person to do armchair exercises, which I enjoyed, but that has stopped”. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 13 Contact with families is actively encouraged, and there were numerous relatives visiting throughout the day. A relative said, “Staff are always very welcoming, and always offer me refreshments – I can just drop in at anytime”. Another said, “I ring each week to ask how she (her relative) is, and staff are always able to give me a clear update”. Staff were observed to offer service users choices at every opportunity. One service user said, “I go to bed and get up when I want – but I’m always late for breakfast”. Staff said that they try to offer choices as much as possible, and stressed the importance of encouraging service users to do as much for themselves as possible to maintain independence. A residents meeting was held in September, when service users were consulted about menus and activities. Contact details for three different advocacy services are displayed on a notice board for service users. Service users praised the standard of the food served. They said that individual choices are catered for. One said, “I’m a fussy eater, but they always find me something nice”. Catering staff discuss menu choices with service users each day, and have a good knowledge of individual likes and dislikes. Service users who require assistance at mealtimes were offered good support. Individual records of food eaten are kept. Broadoak Lodge DS0000001816.V323849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures for dealing with complaints and the prevention of abuse safeguard service users. EVIDENCE: The complaints policy is displayed at various points around the home, and has been amended to include the contact details of the commission. A letter was sent to all relatives in August, reminding them of the procedure. A relative said that she had made a complaint over a year ago, and that this had been taken seriously and resolved by the manager. Staff demonstrated a good knowledge of the procedure to follow if they suspected that abuse had occurred, and confirmed that they have received training. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 15 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, and provides a comfortable environment for service users to enjoy. EVIDENCE: The home has a large communal sitting room and dining area, and a smaller quiet/smoking room. All bedrooms are en-suite, and are personalised to taste. Two residents live independently in an upstairs flat, accessible by stair lift. The home is well maintained, but two bedroom carpets require cleaning or replacing, and two sets of drawers in service users bedrooms were broken. Staff said that these issues were being attended to, but a relative commented that the drawers had been broken “for about two years”. He said, “They keep fixing them, but they just break again”. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 16 Relatives and service users praised the standards of cleanliness in the home. A service user said, “The home is always nice, clean and tidy”. A relative said, “The home is very good – it never smells – the bedding is always spotless”. Broadoak Lodge DS0000001816.V323849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels enable service users to receive a good level of support. Staff receive training to enable them to carry out their role effectively. EVIDENCE: Staff said that there are usually five carers on duty in the morning and four on duty in the afternoon. In addition there are cleaning and catering staff, and the manager. Staff described the arrangements as “pretty good”. A service user said that the staff work “very hard”. There has been a low staff turnover, which has provided stability, and ensured that experienced staff are on duty. Three staff files were inspected. Although they contained copies of two references, and Criminal Record Bureau checks, there was no evidence that the staff had Protection of Vulnerable Adults (POVA) checks in place prior to commencing employment. This information was requested following the inspection, but was not received. Therefore, it was not possible to fully assess this standard. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 18 Staff said that the training available is “good”. A majority of staff have completed or are undertaking National Vocational Qualifications (NVQ). They confirmed that they receive regular mandatory training, both in-house, and via external providers. New staff complete a workbook as part of their induction, and a new member of staff said that her induction had been helpful. Broadoak Lodge DS0000001816.V323849.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and organised, but some health and safety issues were identified, which could potentially put service users at risk. EVIDENCE: Staff, service users and relatives said that the home is well run. Documentation was well organised, and servicing records, and health and safety checks were up to date. Staff commented on the good teamwork and morale, but said that supervision was not occurring regularly, which was confirmed by records inspected. It is recommended that staff receive formal supervision six times per year. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 20 There are satisfactory systems in place for accounting for service users personal money that is sent in by relatives. The balances of three were checked, and all corresponded with records. During a tour of the building, a number of health and safety issues were identified. • A cylinder of oxygen was found in the staff room next to a radiator. There were no signs to indicate that oxygen was stored in the room. Staff explained that the cylinder was no longer in use and was awaiting collection. Arrangements were made to have the cylinder collected urgently. A cleaning trolley with a large container of bleach, and some ant killer was left unattended in a bedroom whilst a member of staff was on her break. The hazardous substances were removed and stored appropriately by staff. Denture cleaning tablets are stored in some service users bedrooms, but there are no risk assessments for this. Some speaker wires from a hi-fi system were loose under a table used by service users, presenting a trip hazard. Staff arranged for these to be taped up and secured to the wall. • • • Staff attended to all these issues promptly, so no immediate requirement was made. Broadoak Lodge DS0000001816.V323849.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 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 2 x 2 Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 13(4) Requirement The registered person must ensure that all areas of the home are safe. Timescale for action 31/01/07 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 OP36 Good Practice Recommendations It is recommended that staff receive formal supervision 6 times per year. Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Broadoak Lodge DS0000001816.V323849.R01.S.doc Version 5.2 Page 24 - 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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