CARE HOMES FOR OLDER PEOPLE
Broadoak Lodge Sandy Lane Melton Mowbray Leicestershire LE13 0AN Lead Inspector
Helen Abel Unannounced Inspection 5th December 2005 09:15 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.V271039.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. Broadoak Lodge DS0000001816.V271039.R01.S.doc Version 5.0 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 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.V271039.R01.S.doc Version 5.0 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 4th August 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 Sandy Lane in Melton Mowbray. 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.V271039.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced during a weekday morning over a four- hour period. Residents, staff and visitors were interviewed. A part tour of the premises took place and some staff, care records, and policies and procedures were inspected relating to the management of home. The home was busy the morning of the inspection as a group of residents prepared to attend a Christmas tree service at a local church. A private hairdresser was busy attending to individual residents. What the service does well: What has improved since the last inspection?
The Registered Provider has dealt with some concerns raised by residents: the garden area and staff handover periods. Decorating improvements have been made to the identified bedrooms in order to provide a more pleasant environment. The outdoor courtyard is being improved with ongoing maintenance and upkeep. This should provide a pleasant and enjoyble outdoor area, for residents to spend time in during the warmer weather. The kitchen fire door is now kept closed to further safe guard residents. Training for staff has been arranged to ensure they have the necessary skills to meet the needs of the residents. Resident’s risk assessements have been reviewed and updated to ensure they reflect changing needs of individals. More bananas have been purchased and
Broadoak Lodge DS0000001816.V271039.R01.S.doc Version 5.0 Page 6 made available to residents as part of the menu and served in fruit bowls in communial areas. The residents satisfaction questionnaire update now includes details about the improvements made, following on the consulation period. 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. Broadoak Lodge DS0000001816.V271039.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 Broadoak Lodge DS0000001816.V271039.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): 1,3,4,5, Assessment processes are fully implemented, which ensures that the service meets the prospective resident’s needs. EVIDENCE: A copy of the Service User Guide is given to new residents, which includes key information about the home. All residents are assessed prior to entering the home and visits are arranged for residents, their families and friends. One family visited several times to discuss and decide on the suitability of the home before the individual took up the provision. Broadoak Lodge DS0000001816.V271039.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): 9,10 Medication policies and procedures around medicines protect residents; residents are treated with respect and their right to privacy upheld. EVIDENCE: Medicine and medicine records were sampled and were well organised and in order. An issue around the disposal of medicine was discussed and advice sought from the Commissions Pharmacist Inspector. Staff were observed talking with residents in a kind and gentle way. The Inspector observed staff knocking on resident’s doors before entering to bring in fresh laundry. Broadoak Lodge DS0000001816.V271039.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): These outcomes were inspected at the last inspection and were all compliant. EVIDENCE: Broadoak Lodge DS0000001816.V271039.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): 16,17 Residents complaints are not listened to and taken seriously, which may lead to issues of protection. EVIDENCE: There were various concerns raised from some residents from the last inspection. This was reported to the Registered Provider but has not been fully acted on. Residents had repeatedly requested butter but this had not been provided. The cook had been provided with a butter alternative but this was not what residents wanted. The toilet paper was reported to be very thin and of poor quality. The complaints procedure displayed did not contain the telephone number or fax number of the Commissions. The Registered Manager agreed to update this immediately. One resident said, “ I have no complaints this is a lovely home.” A visitor confirmed, “ This is a very good home, I have no complaints. The food is good here.” The Registered Manager confirmed residents are provided with a range of information around advocacy services and passed onto solicitors if that is what residents request. Broadoak Lodge DS0000001816.V271039.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): 20,21,22,23, 24,25,26 The premises are very well maintained, safe and comfortable, clean and hygienic with good processes in place to minimise any risk of cross infection. EVIDENCE: Residents rooms are clean and tidy all very individual with residents personal items and furniture. The cleaning is off a very high standard with springcleaning sessions taking place regularly. The lounge areas were comfortably set out with bowls of fresh fruit placed on small side tables. A pet budgie is kept in a cage in the large lounge and amuses the residents. The laundry area was very clean and well organised with all staff contributing to the running of this area. Some aspects had been identified for maintence and this was recorded in the maintenance book. A residents armchair arm rest was ripped. The Registered Manager agreed to see to this straight away.
Broadoak Lodge DS0000001816.V271039.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): 29,30 Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staff recruitment records were sampled and are well organised and contain the required information. Staff training is on going and a staff member reported, “I have done food hygiene training, moving and handling and National Vocational Qualifications in care level 2.” All staff that administers medicine have medication training and all senior staff have first aid training. This essential training safe guards residents from harm. Broadoak Lodge DS0000001816.V271039.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): 33, 34,35,36,37,38 The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Safeguarding of residents financial records are in order and held securely. Staff have regular staff meetings with clear records held and demonstrated clear evidence of running the home in the best interests of the residents. Staff have regular supervision and appraisals, and informal support and guidance on a daily basis from the Registered Manager. All record keeping viewed was up to date and in good order. All health and safety checks were compliant. Discussions took place with the Registered Manager around providing induction and foundation training that meets the National Training Organisation for Social Care.
Broadoak Lodge DS0000001816.V271039.R01.S.doc Version 5.0 Page 15 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 x x 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 3 3 3 3 3 Broadoak Lodge DS0000001816.V271039.R01.S.doc Version 5.0 Page 16 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 OP16 Regulation 22 Requirement The Registered Person shall ensure the complaints identified upon the August 2005 inspection are promptly investigated and concluded. The complaints procedure to include the telephone number of the Commissions. Timescale for action 12/12/05 2 OP16 22 12/12/05 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 OP38 Good Practice Recommendations Providing new staff with: Induction and foundation training that meets the National Training Organisation for Social Care. This includes training on the principles of care, safe working practices, the organisation and worker role, the experience and particular needs of the resident group and the influences and particular requirements of the service setting. Broadoak Lodge DS0000001816.V271039.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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