Inspection on 05/10/07 for Broadoak Lodge

This inspection was carried out on 5th October 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 04/01/07

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 Thea Richards Unannounced Inspection 5th October 2007 10:45 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.V348660.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.V348660.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.V348660.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 4th January 2007 Brief Description of the Service: Broadoak Lodge Residential Home is a care home providing personal care and accommodation for 27 older people with a physical frailty and/or mental health needs. The home is owned by the Registered Providers Mr and Mrs Nunn and is part of fifteen homes owned by the Broadoak Group of Care Homes. Christine Carne has been the manager for several years. The home is situated on the outskirts of Melton Mowbray and can be reached by private and public transport. There are local shops close to the home. The accommodation is a purpose built two- storey home with two lounges and a dining room on the ground floor. There are bedrooms on both floors and the first floor can be reached by stairs or by a passenger lift. There are single and shared bedrooms, all of which have en-suite facilities. Outside, there is a well – maintained patio area with seating and flower beds, which is easily reached for the residents to use in the better weather. The current registration certificate from the Commission for Social Care Inspection is available in the reception area with an up to date insurance certificate. The latest report from the Commission for Social Care Inspection is available in the managers’ office. The home’s brochure provides information about the service to prospective and current residents and includes the terms and conditions of the stay. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 5 The home can be contacted by telephone, or fax. The current level of fees is £ 465.00 There are extra charges for hairdressing, chiropody, newspapers and personal items. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of a care home for older people, which ended with an unannounced visit to the service. Before the visit the inspector spent four hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the 4th January 2007. This included the Annual Quality Assurance Audit completed by the home. The visit took place on the 5th October 2007 and lasted five and a half hours. During the visit the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that the inspector looked at the care provided to three of the residents. To achieve this, the residents were spoken with. The inspector spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission the residents’ bedrooms were looked at. The inspector also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. The inspector looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. The inspector looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit the inspector spoke with the manager, staff, the residents and their families. What the service does well: There is a very good admission process, which gives the prospective resident and the staff good information to help the residents settle into the home. There are thorough care plans, which are agreed with the resident and / or their families, to give the care that is needed. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 7 The staff give good care to the residents and are well trained, with a high level of staff with an NVQ at level 2 or above; ‘The staff are very good and care well for us’. There is a good range of activities and choice of meals. The residents have a safe and pleasant environment to live in. What has improved since the last inspection? What they could do better: They could produce the Statement of purpose and the Service User guide as separate documents to make it easier for the residents to understand. These documents could be produced in other formats, such as large print or other languages to help understanding. The daily record of care should be reviewed to be written to reflect the residents day and condition. The complaints book should be designed to include the dates of the complaint and the date when it was resolved. This would provide evidence that it had been dealt with adequately and within the given timescales. The complaints policy should be produced in other formats, such as large print and other languages to help the residents understand it. The maintenance department should attend the home at a frequency that makes sure that all outstanding matters are dealt with as soon as they are identified. The in-house trainers should have regular up dates in the subjects, which they are teaching, to make sure that the staff have the best training possible. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 8 Notifications of incidents occurring in the home should be sent to the Commission for Social Care Inspection as soon as possible to make sure that they are aware of these. Risk assessments for all identified risks for the residents must be produced to protect the residents and the staff and to allow the residents to undertake activities safely. 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.V348660.R01.S.doc Version 5.2 Page 9 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.V348660.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ needs are always assessed before moving into the home and they are offered the chance to visit the home. They are given adequate information to allow them to make an informed choice about the home. EVIDENCE: All of the residents who were ‘case tracked’ had been given a Statement of Purpose and terms and conditions. Following a review of their registration certificate Broadoak Lodge should revise their statement of purpose. A separate service users guide should be provided. Consideration should be made to make these in other formats, such as large print or other languages, which will help people to understand the information. Providing a comprehensive Statement of Purpose & Service Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 11 Users’ Guide results in good information for the residents, making sure that they they can get the most suitable care. The manager or the deputy manager visits all prospective residents before they are admitted to the home and complete a pre admission assessment form. These were seen in the files looked at. This makes sure that that the manager and the staff in the home have the the right information before the resident is admitted, so that they get the best care. It makes sure that the home can meet the residents needs and that the resident meets someone from the home who they can recognise. This makes the move into care easier to manage for them. The families spoken confirmed that they were given the opportunity to visit the home before their relatve came in. There was the opportunity for prospective residents to come for a meal, spend the day or a week-end at the home to see if they liked it before they made a decision to move in. Once they have moved in they have a month’s trial to see if they wished to stay. Members of the staff spoken with said that they usually knew what the residents needs were before they moved in. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home. The latest report from the CSCI was available in the managers’ office. An up to date insurance certificate was displayed in the entrance hall. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 12 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. The staff meet the care needs of the residents as identified in the care plans, which the residents and their families have agreed with. EVIDENCE: All of the ‘case tracked records were found to contain good individual evidence of the care being given to the residents. There are records of the involvement of G.P.s, district nurses, chiropodist, optician and dentist in them, showing that thorough health care is being provided for the residents. The residents and their families spoken with said that they could see the doctor and other health professionals when they needed to. There are records of the residents weight and of the meals that they have eaten, which makes sure that they are having an adequate diet. The care plans seen had been signed by the resident or their families and Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 13 those spoken with said that they had been involved in the review process and were happy with the care being given. The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. However the daily record should be reviewed to make sure that the entries are meaningful and properly reflect the residents day. The inspector saw the residents being treated with dignity and respect when staff spoke with them and gave them their care. Staff seen giving care did so in the right way, giving the residents privacy where needed and communicated with them whilst giving the care. Staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. A comment from a resident was ‘ the staff are very good and care well for us’. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff who have had training to give medicines. The medicine round was seen by the inspector and medicines were administered individually and the residents seen to be taking them. The staff spoken with were knowledgeable about the medicines and where to obtain information. They were also aware of the requirements for the receipt, storage and disposal of medicines. The deputy manager regularly looks at the record sheets but does not record this. She should consider formally auditing the records and recording the results. The chemist who supplies the medicines regularly audits the medicines and these were in order. There is a policy for residents handling their own medicines, whilst there are no permanent residents looking after their own medicines at the moment, a resident who is in the home temporarily does administer her own and a risk assessment has not been completed. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 14 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. Residents have their social, spiritual and nutritional needs met. Their views are taken into consideration and acted on. EVIDENCE: There was evidence of activites being provided for the residents. The residents and the families spoken with were happy with the amount and variety of activity arranged. On the morning of the visit the residents were enjoying playing bingo. There is regular musical entertainment which the residents enjoy. There were several visitors in the home on the day of the visit and those spoken with were positive about the communication with the manager and said that they were always made very welcome in the home. They felt that the level of activity arranged was suitable for the residents and they are invited to activities and may have a meal with their relative. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 15 During the period after lunch when there were a lot of staff around, there was very little interaction with the residents, who were sitting in the lounge with inappropriate music playing. At other times during the visit the staff were seen to be spending individual time with the residents. The residents have a choice of meals every day and the cook is enthusiastic in producing meals which the residents enjoy. The inspector spent time the dining room during lunchtime and all the residents spoken with said that they were enjoying their meal and that they always had a choice. The cook has a good understanding of the dietary needs of the residents including diabetic diets. The staff were seen to be sitting and talking with the residents whilst helping them with their meal. The manager or the deputy sees each of the residents on a one to one basis every day. There are annual quality audits to get the views of the residents and their families. These practices make sure that the residents keep their contact with the community and their families and that views for improvements can be considered. Religious needs are provided for, with a monthly service and a priest who visits regularly. A hairdresser visits the home weekly which the residents enjoy. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 16 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. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to if they needed to. The policy is not produced in other formats such as large print or other languages, which would make it easier to understand. The complaints book was looked at and was found not to have adequate record of any complaints with no dates to show when complaints had been received or when they were resolved. Complaints received since the last inspection on the 4th January 2007 had been resolved satisfactorily. The residents spoken with were happy that they would speak to the manager or a member of staff, if they had a problem and that it would be dealt with. Families spoken with on the day of the visit said that they were aware of the procedure to complain and would have no concerns about doing so. The staff spoken with knew how to deal with a complaint which was given to them. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 17 The staff confirmed that they had had training in safeguarding adults and this was confirmed by the training records held in the home. The staff spoken with told the inspector how they would handle such an incident and that they would have no concerns about ‘whistleblowing’. This makes sure that the residents are safe from any abuse and that any concerns are handled correctly. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 18 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, 20, 23, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a pleasant home, which is run in their best interests. EVIDENCE: Broadoak Grange is a purpose built home on the outskirts of Melton Mowbray. There are two lounges, only one of which is generally used. This has a television and music centre. There is one dining room, where all the residents can enjoy their meals. The home is well maintained, clean and free from any unpleasant odours and it gives the residents a pleasant place to live in. The person who does the maintenance is shared between all the homes in the group, which means that the home often has to wait for routine maintenance tasks. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 19 There is a pleasant patio area, which is very well kept and easy for the residents to get to in the better weather. The bathrooms are clean, tidy and free of any hazards. One bathroom did have some unnamed toiletries in it, which could be a hazard for the residents if someone who is confused drank them. They could cause cross infection if used for more than one resident. This was shown to the deputy manager, whom had the items removed before the end of the visit. With their permission, the case tracked residents bedrooms were looked at by the inspector. They provided good accommodation, which had been personalised with the resident’s belongings. The bedrooms were clean and well maintained. There was evidence of equipment such as hoists having been provided to help in the care and comfort of the residents. The cleaning materials were kept in locked cupboards and the staff have had training in handlng dangerous chemicals. The home has now purchased its own carpet cleaner, which makes sure that they can be cleaned when it is needed and not have to wait for the shared machine to be brought. This will reduce the risk of cross infection between the homes. The maintenance, hot water temperatures and fire records were checked and found to up to date and in order. However, there was one bedroom where the water temperature had been raised for several months. This had been reported to the maintenance staff but to date had not been resolved. The resident in this room is not at risk as they are not mobile, however this must be resolved as soon as possible. There were no further outstanding safety or maintenance issues seen on the tour of the premises. The registration certificate from the Commission for Social Care Inspection was displayed with a current certificate of insurance. The inspection reports are available in the managers’ office. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 20 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. The residents’ needs are met and their safety protected by the recruitment policy and by the training that is in place. EVIDENCE: There is evidence of a good skill mix of staff to make sure that the residents have the right care. The duty rota reflected the number of staff on duty. The residents, staff and relatives spoken with felt that there were always enough staff on duty to look after them properly. Three staff files were looked at by the inspector and the required information was complete in all of the files. This included evidence of identification, adequately completed application forms, two written references and Criminal Records Bureau checks. The application forms should be reviewed to include the dates of previous employment so that the manager can explore any gaps in the history. There were records of staff training including induction and the staff spoken with confirmed that they received regular training in moving and handling. They said that they had training in first aid, food hygiene and medicine training. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 21 The company employ an ‘in-house’ trainer for the mandatory training requirements and there was some concern expressed by staff that they may not be up to date in their teaching. There is a record of training held by the manager with the certificates in the staff files. The home has 23 members of staff with a National Vocational Award (NVQ) at level 2 or above. with another five about to start. This is well above the required numbers of 50 of staff and is to be commended. The manager has completed the registered managers award through the National Vocational Award programme. The National Vocational Qualification is a qualification for care staff to make that they receive the right training in the needs of the resident group whom they are caring for. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 22 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, 36, 38.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is committed to the best care for the residents through training, good communication and thorough recruitment practice. EVIDENCE: The deputy manager was available throughout the visit to the home. The manager is an experienced manager who has completed her registered managers award. The manager is well supported by her deputy who is a very experienced manager and is helping to make improvements to the home. There was evidence that regular staff supervision was in place, with the responsibility being given to senior staff in different areas, such as a senior Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 23 carer on night duty and the cook. The members of staff spoken with confirmed that they had received regular supervision. The process of formal supervision time gives the staff and their ‘line manager’ the opportunity to have individual discussions about work and training needs. There are regular meetings held with the staff to pass on and exchange information. The manager meets regularly with the residents and their families as well as one to one discussions both to pass information on and to listen to their views and opinions. There are annual quality questionaires sent out to residents and their families to gain their views about the home. These practices allow the manager and the responsible person to respond to the residents and the staff’s needs. There are accounts held to manage the residents personal allowances and are being managed correctly with two signatures and the receipts in place. The policies and procedures are in place for the home and are regularly reviewed. They are available for the staff to read to make sure that they know how the residents are to be cared for. The Commission for Social Care Inspetion has not received any notifications (reg 37) of incidents at the home since the last inspection on 4th January 2007. This was brought to the attention of the deputy mnager who said that she would put them in place immediately. Records for the maintenance of fire equipment, fire drills and training were found to be in place and up to date. The registered provider completes a provider report (Reg 26) every month and there is a copy kept in the home. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 24 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 2 3 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 2 17 X 18 3 1 3 X X 3 3 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 3 X 1 Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23(2)(j) Requirement That the water temperature in the identified bedroom is adjusted to comply with the required temperature. That notifications are made to the Commission for Social Care Inspection for all deaths and incidents affecting the well being of the residents or staff. Timescale for action 12/10/07 2. OP38 37 05/10/07 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. 2. Refer to Standard OP1 OP1 Good Practice Recommendations That the Statement of Purpose and Service User Guide are produced as separate documents to make each easier to understand. That a facility is provided to produce the Statement of Purpose and the Service User Guide in different formats to make sure that all the residents and their families can understand them. That the daily record of care is written to make sure that it contains an accurate and meaningful report of the DS0000001816.V348660.R01.S.doc Version 5.2 Page 26 3. OP7 Broadoak Lodge 4. 5. 6. OP9 OP16 OP16 7. 8. 9. OP19 OP30 OP38 residents’ day or night. That a risk assessment is put in place for any medicines being self medicated. That the complaints’ policy is produced in formats that the residents and their families can understand. That the complaints book contains thorough information including the dates on which the complaint was received and the date that it was resolved. This will provide an audit trail to confirm that the complaint was resolved within the required timescales. That the frequency of maintenance visits is increased to allow routine and urgent maintenance tasks to be completed. That the in-house trainer receives regular updates to make sure that the staff have up to date training. That risk assessments for all identified risks have assessments in place. Broadoak Lodge DS0000001816.V348660.R01.S.doc Version 5.2 Page 27 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.V348660.R01.S.doc Version 5.2 Page 28 - 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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