CARE HOMES FOR OLDER PEOPLE
Broadoak Manor Nursing Home Mulcrow Close Parr St Helens Merseyside WA9 1HB Lead Inspector
Miss Diane Sharrock Unannounced Inspection 10:00 30th August 1 2 September 2005
st nd 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 Manor Nursing Home DS0000005452.V258518.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 Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Broadoak Manor Nursing Home Address Mulcrow Close Parr St Helens Merseyside WA9 1HB 01744 615626 01744 615301 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) BUPA Care Homes (CFH Care) Limited No. 2741070 Mrs Nicola Jayne Garner Care Home 120 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (84), of places Terminally ill over 65 years of age (6) Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Service users to include up to 84 OP and up to 30 DE(E) and up to 6 TI(E). The service should employ a suitably qualified and experienced manager who is registered with the CSCI. To have 1 temporary registered bed for a named service user who is under 65 years of age To admit a named Service user Mrs LG who is currently 52 years of age 1/2/3 September 2004 Date of last inspection Brief Description of the Service: Broadoak Manor Nursing Home is owned and run by BUPA. The Manager for the home is Mrs Pauline Mellor, whom is a trained nurse. An application has not yet been received for the Manager to be registered with CSCI. The previous Registered Manager is currently on leave. The home is situated in the St. Helens area, and is close to local shops and road links. The home is a modern, purpose built facility and is registered for 120 beds. The home can accommodate 84 physically disabled/older persons, 30 EMI and 6 palliative care Service users although at present the home do not currently admit Service Users for Palliative care. The home is all located on one level and broken down into four smaller units of 30 beds. These units are named Stapley, Ashton, Ravenhead and Havanagh. Each unit has a designated Senior Nurse who has day-to-day responsibility for the provision of care. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 3 days and was unannounced. It was carried out as part of the regulatory requirement for care homes to be inspected at least twice a year. A complaint investigation was also conducted as part of this inspection. The Inspector has also carried out further visits to the home following this inspection to investigate an adult protection investigation and to carry out additional visits on the 5/10/05, 20/10/05, 26/10/05. An immediate requirement was served on the 5/10/05 to review care plans on Stapley unit. The company submitted an action plan detailing their actions and following further reviews by the Local Authority the Company extended their reviews of care plans and issues identified with a further action plan submitted to CSCI. This report has been delayed due to the adult protection investigation which provided an extensive review of care by the Local Authority and ongoing monitoring of regulations at the home. Company Representatives have agreed to meet with CSCI after the conclusion of the adult protection investigation. A partial tour of the premises took place and Resident care plans and various other records were inspected. Most Staff on duty, Residents and relatives chatted openly with the Inspector. A selection of comment cards were left and some have already been sent to the CSCI offices. In total 8 have been received. 2 of these comment cards were positive however 6 detailed various comments about staffing levels, the food, being unaware of the complaints procedure and not being consulted about the care. The Manager Mrs Mellor represented the home. All areas of the inspection and findings were discussed with the Manager at the end of this inspection and copies of the feedback were given to the Manager at the close of this inspection. Most Comments made by Residents and Relatives during the inspection were complimentary about the staff and care received. What the service does well:
The home employs a full time Manager and two Administrator’s. In-house Quality assurance and audit systems are in place. The home also have their own Training Coordinator who works 12 hours a day. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 6 The home was found to be clean and tidy. The home has an ongoing maintenance and decoration plan. The home has a detailed Statement of Purpose and a Service User Guide which are displayed in reception and in each of the units, each bedroom also has a Service Users guide available. Some of the standards are showing evidence they are being met as the company’s standardized paperwork covers relevant areas. The Staff involved with this inspection were noted to be friendly and welcoming to all visitors to the home. There were various compliments from a sample of Residents and Relatives about the Staff and the care received. What has improved since the last inspection? What they could do better:
All areas of the inspection and findings were discussed with the Manager at the end of this inspection and copies of the feedback were given. Other areas of development were mainly in showing evidence of a planned management approach in various areas, and showing evidence that all parties are included in the overall management and organisation of the home. Overall review was needed to develop activities suitable to resident’s needs and requests on all units.
Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 7 Staffing levels should be reviewed with all parties as all comments cards stated they felt that the units needed more Staff. Staffing levels on Ravenhead should also be reviewed in light of comments raised. Staff felt they did not always get cover for sickness and some Residents with funding for 1 to 1 support on occasions staff state they did not get this due to staffing shortages. Care issues on various units which have been identified and pointed out to the Manager during this inspection should also be reviewed and appropriate action taken. Ravenhead Careplans should be reviewed to give appropriate details for social support. Staff and Relatives felt that “they needed another carer to improve the quality of care”. They feel they should have an increase to staffing levels in the mornings. Stapely Staff and Residents stated they were unaware of when the refurbishment programme would start, they felt they were in need of a lounge carpet but did not know whether it was being replaced. Staff and Residents stated they were unaware of whether the current vacancies were being advertised for 1 RGN, 1 Carer and 1 Hobby Therapist. No details were displayed of activities and 1 Staff member did this whenever she could fit this into her role. Care issues needed to be reviewed including the use of “kirton chairs” and supporting Residents assessed as needing such a chair. Care plans should be reviewed to give appropriate details for social support. One care plan needed further details for the persons behaviour so that the home can demonstrate this person is receiving the care and support specific to this persons needs. Havannah Staff stated that due to recent sickness they were instructed to work with lower staffing levels than the agreed minimum levels. Staff did not seem aware of the Companies procedures in the event of absenteeism and bringing additional staff in to replace them. The company policy identified that any 1 to 1 funded care would be identified ion a separate staffing rota, however this had not happened on this unit. Individual training plans needed to be updated, especially for Abuse awareness training and load management. Care plans needed to be reviewed and include appropriate details for social support, use of wheelchairs and appropriate use of lap straps and 1 to 1 support. The use of mattresses on floors should also be reviewed as a matter of good practice the company had previously supplied a “futon style” bed frame for 1 Resident. Ashton Care plans needed to be reviewed to include appropriate details for social support, 1 to 1 support, challenging behaviour, risks associated to challenging behaviour. Access to suitable equipment like armchairs must be provided if a Resident has been assessed as needing it. Training plans need updating and to show evidence that staff have received mandatory training.
Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 8 General care issues needed review, including appropriate dressing of Resident and review of appropriate clothes and resources e.g. stockings, socks, shoes and slippers. A review of staff practices in supporting Residents in appropriate chairs specific to that persons needs. And a review of care practices to identify any risks or support needed for Residents during the course of the day. 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 Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 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 Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Senior Staff carry out detailed assessments of each new Residents needs so that the appropriate care and admission to the home can proceed. EVIDENCE: There have been several Service Users admitted to the units since the previous inspection. Initial assessments for newly admitted Service Users were available for inspection. Most records contained all information as listed in this standards however some assessments had not been completed in full by staff. Residents and Relatives comments were complimentary about the care received during this inspection however just 2 comment cards reflected similar opinion. 6 comment cards gave various comments detailed further in this report. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 11 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): 7.8.9.10 There continues to be progress made within care plans which include details for health, personal and some parts of social care needs of Residents. Further developments need to take place to meet all parts of this standard, although the standardized paperwork is provided by the Company. Most Residents were happy their needs were being met, some aspects of care was in need of review. Medication procedures were found to be in good order with a well organised medical room EVIDENCE: The Inspector evidenced this standard through visiting each of the units and viewing a selection of Service Users plans and having general discussions with Residents/Relatives and Staff..
Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 12 General Comments Care plans were available for all Residents. A number of care plans on units have been developed since the previous inspection. Some were found to be very detailed and others were found to need more information and updated to reflect the Residents needs, especially social care needs on all units. Specific review of identified care plans were discussed with the Manager who agreed to arrange further reviews to ensure the plans were up to date and appropriate for the Residents needs. 2 comment cards state they are not consulted about their care and 2 comment cards state they sometimes like living at the home and sometimes felt the Staff treated them well. 1 comment card stated they did not like living at the home. Ashton One care plan identified that one Resident was not always receiving their 1 to 1 support. The Manager agreed to review this with the care Manager. One care plan identified that the Resident needed a “specialised chair, and without the chair this persons care was being affected as they were cared for in their bedroom. One care plan did not have details or risks of the Residents challenging behaviour, even though an incident had been recorded in the incident book for July 2005. Again the Manager agreed to review these care plans to ensure they are updated and detailed to provide appropriate care. Havannah One care plan identified that a lap strap was being used for one Resident when in their wheelchair. This plan was identified as needing review and the use of the 1 to 1 funding for this person. Stapely One care plan was found to be in need of review regarding one persons behaviour as it was not described in their care plan. The Homes Manager also undertakes a monthly audit on the progress of any wounds, which may have developed and a sample audit of care plans. Medication and records on units were examined. Those Medications seen were appropriately stored in all units. Ashton unit had one record on the medication sheet not signed and a GP instruction to decrease one medication had no details in writing about this. This was discussed with the manager including the Staffs limited understanding of the medication concerned. Records that were examined were recorded appropriately. A medication policy was available on all units. This area is managed by the Nurses at the home and was found to be mostly well organised. The home are not currently admitting Residents under the category of palliative care however the homes Manager explained various plans for the future were they would hope to reinstate this facility. This standard was not measured at this inspection. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 13 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. Standards for activities are not met. An action plan must be provided to evidence what actions will be taken by the company to meet this standard and regulation. EVIDENCE: Most units had an Activities co-ordinator employed for 13 hours per week. Some care plans have been developed to include more information about Service Users interests. However some did not have the necessary details or social care plan in place. Care Staff explained they do not necessarily have time to arrange activities.. Interviews with Residents identified that activities were very limited and were not meeting Residents needs or requests These comments were also reflected in the comment cards received, one comment stated, “I think there should be someone to give them stimulation instead of sitting there all day, someone to keep their minds active.” A selection of Residents bedrooms was viewed during the inspection. All were personalised reflecting the Residents likes and choice. Each unit is holding regular Resident and Relatives meetings enabling Service Users the
Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 14 opportunity to express their views. However some units did not organise these events. Standard 15 was not measured in full during this inspection however the following points were raised as detailed below. During general discussions Residents expressed satisfaction with the food that is provided on the units. However 2 comment cards stated they liked the food sometimes. One comment stated, “ Is fish fingers and peas or a sausage roll or a hotdog sufficient for an adult lunch.? Or a round of bread as a sandwich. There is no variety in desserts other than different types of mousse or blancmange or jelly, not all Residents need soft food, not all Residents use the lounge were fresh fruit is kept.” Meal times are set, however, the Nurses in Charge and Staff stated that meal times could be flexible based on the needs and wishes of the Service Users. On the day of the inspection the majority of Service Users ate their meals in the dining room, several Service Users, ate their meals in their bedrooms. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 15 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): 16.18 The home has a complaints policy that is available. Most Staff are trained in “Abuse Awareness” and know about the policies that should be carried out. . A review of Staff competencies with the Adult protection policy should take place. Training records should be developed to show ongoing evidence and commitment to keep Staff updated in abuse awareness training. EVIDENCE: A sample of Staff training records showed evidence of the ongoing training provided in “Abuse awareness”. However some records had not been updated and some staff had not received recent training. One care plan seen gave details of a wheelchair lap strap being used for one persons care. This raised issues around Staff needing to be updated in the Adult protection policies and appropriate training. This was discussed with the Manager. 2 comment cards stated they were unaware of the homes complaints policy. Bedrooms seen were noted to have Service User guides in place which also contained a copy of the homes complaints procedure, some units also had it displayed on notice boards. As some people stated they were unaware of the procedure, the company should look at other ways of communicating necessary information to everyone, especially in arranging regular minuted Resident and Relative meetings. The Inspector also conducted a complaint investigation during this inspection and also visited on the 5/10/05 to assist in conducting an adult protection investigation. Most parts of this complaint were upheld and an immediate
Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 16 requirement was served. The Company have produced various action plans to meet the immediate requirement served on the 5/10/05 . These action plans and requirements have been reviewed on the 20/10/05 and 26/10/05 and will be also reviewed and measured at the homes next inspection. Points raised about individual Residents in a PCT report of the 27/10/05 and a social care report by St Helens Care Managers prompted a further extended timescale for the Company to extend their current review of care to all units. .( this timescale was extended to 22/11/05. The Company have submitted this action plan within the timescale. Company representatives have co operated fully with each investigation and have produced necessary documents both during and following this inspection. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 17 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): 26.22. The environment is well managed and kept clean and tidy. Sufficient equipment is available for the Staff to use in ensuring that the hygiene and cleanliness levels are maintained. EVIDENCE: All units were observed to be clean, tidy and bright and well organised. Most Residents and Relatives were happy with the facilities and their bedroom areas. Most people were happy with the ongoing maintenance and redecoration programme however; On Stapely, Staff and Residents were unaware of the details of the refurbishment programme and felt they needed a replacement of the lounge carpet. A maintenance and decoration plan should be developed and discussed with everyone so that they can be involved in the developments for their home. On Ashton it was noted that 2 Residents did not have specialised armchairs specific to their needs, this was discussed with the Manager who agreed to review this situation. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 18 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): 27.30. Further training is still to be provided and training records need further development and review to evidence all parts of this standard are being met. Residents and Relatives Staff and 5 comment cards received say they feel there are not enough staff at the home. EVIDENCE: Rotas showed that most units were staffed on the day of inspection meeting the minimum Staffing levels. Staff did indicate on Ashton that some Residents that had funding for 1 to 1 support did not always get this due to sickness of staff and absenteeism. Staff on Havannah stated that due to recent sickness they were instructed to work with lower staffing levels than the agreed minimum levels. Staff did not seem aware of the Companies procedures in the event of absenteeism and bringing additional staff in to replace them. The company policy identified that any 1 to 1 funded care would be identified on a separate staffing rota, however this had not happened on this unit. This points were discussed with the Manager who agreed to review these issues to ensure Residents received the support from the appropriate numbers of Staff at all times. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 19 All comments made during this inspection and via comment cards stated they did not feel the home had enough Staff on duty. 2 comment cards stated they felt well cared for and other comments stated, “Although my” Relatives” care is of a good standard extra staffing levels would greatly improve things.” Another stated, “An extra pair of hands would help the staff on a regular basis we would prefer not to have agency as they are unaware of “ individual” needs.” One comment card stated, “Night Staff, only 3 on nights for 30 Residents is this sufficient in case of emergency.” “Health and Safety, is one cleaner/ housekeeper sufficient to maintain the necessary level of cleanliness and hygiene.” The home as an example of good practice has also employed their own training and development organiser on a part time basis and each unit had a variety of training notices displayed inviting staff to attend the organised event. The company had produced a thorough training plan which gives details of the training available, how it can be accessed and how it will be delivered. The training records still need to be updated and in place for all Staff so that the home can give written evidence of each individuals training to date. Most Staff were clear that they had received mandatory training in the last 12 months. However some had not received training or updates in Abuse awareness and load management. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 20 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. The home has a temporary Manager who is not yet registered with CSCI. Quality assurance needs development to meet all parts of this standard EVIDENCE: The current Manager has yet to submit an application to CSCI to enable her to undergo her interview with CSCI for registration as manager of Broadoak manor. Some units showed evidence how they organise regular meetings to include everyone in developments of the home and to gain their opinions and feedback, however other units did not have regular minuted meetings. General comments from the inspection covered concerns and opinions around “staffing levels being too low” “activities not being appropriate”, and comment cards indicated that they are not consulted about Residents care, inappropriate menus. These overall comments indicate that the company should look at reviewing their current quality assurance tools to elicit opinions from everyone and provide suitable areas of communication.
Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X 2 X X X 3 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X x Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14 2) Requirement For the Responsible Person to review the care of all Residents at Broadoak Manor and submit an appropriate action plan to all points raised about individual Residents in the PCT report of the 27/10/05. To give details of all actions taken by the company to rectify all areas inclusive of St Helens Care Managers social report. .( this timescale was extended to 22/11/05 and an action plan has been submitted to CSCI.) Timescale for action 22/11/05 2 OP7 14 2 3 OP12 16 2 n The Responsible Person is 04/01/06 required to submit a concluding report to CSCI giving an update to all care plans reviewed by the companies auditing process and an ongoing action plan to ensure these regulations will be met at all times. For the Responsible Individual To 04/01/06 review the comments raised during this inspection around limited activities and to submit a detailed action plan stating how
DS0000005452.V258518.R01.S.doc Version 5.0 Page 23 Broadoak Manor Nursing Home 4 OP27 18 5 OP27 18 1)a)b)c) 6 OP31 9 this regulation will be met and what actions have been taken following this inspection regarding these comments. For the Responsible Individual To 04/01/06 review the comments raised by Staff, Residents and Relatives and the evidence found in Staff rotas, regarding staffing levels. The Responsible Person must ensure that the staffing of the home meets the ongoing needs of the Service Users, and submit evidence to the CSCI describing the actions taken to meet this regulation. The Responsible Person is 04/01/06 required to provide evidence that the training needs of staff have been met including training in load management and abuse awareness, record keeping and communication. Please submit an updated plan to the Commission stating what actions will be taken by the company to meet this regulation The Responsible Person is 04/01/06 required to submit an application to CSCI nominating a suitable Manager who is “fit” to manage Broadoak Manor to be registered with CSCI. 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 OP3 OP7 Good Practice Recommendations To provide all information relating to initial assessments on service users care records To develop and provide suitable equipment for e.g. current
DS0000005452.V258518.R01.S.doc Version 5.0 Page 24 Broadoak Manor Nursing Home 3 4 5 OP12 OP15 OP33 mattress positioned on the floor, specialised armchairs and any other equipment specific for Residents needs. To review and develop the activities programme to meet this standard and to meet the needs of Residents. To develop the choices offered with menus and the accessibility of suitable menus. To develop ongoing and regular minuted staff and Resident meetings and develop areas of open discussions with all parties to keep them informed of all matters within the home. Broadoak Manor Nursing Home DS0000005452.V258518.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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