Inspection on 17/09/07 for Broadoaks

This inspection was carried out on 17th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broadoaks 12/08/08

Broadoaks 31/10/06

Broadoaks 16/01/06

Broadoaks 03/08/05

Broadoaks 20/01/05

Broadoaks 20/09/04

Broadoaks 24/03/04

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

CARE HOMES FOR OLDER PEOPLE Broadoaks 2 Southend Road Rochford Essex SS4 1HA Lead Inspector Bernadette Little Unannounced Inspection 17th September 2007 10:00 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 Broadoaks DS0000018064.V347142.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. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadoaks Address 2 Southend Road Rochford Essex SS4 1HA 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) 01702 545888 01702 546442 Eastwood Hall Limited Mrs Agnes Stubbings Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2006 Brief Description of the Service: Broadoaks is a large detached 19th century Manor House situated close to Rochford town centre. Care and accommodation is provided for twenty residents. The home is not registered to admit service users who are diagnosed as suffering from dementia. Accommodation is provided on two floors with a shaft lift to enable access. Bedrooms are all single rooms with en suite facilities. The Home has two lounges, a pleasant dining room and a visitors room. There is parking to the front of the building and a secure garden with seating available to the side of the building. The Home shares a minibus with three sister homes, and this is available to provide transport and outings for service users. The registered providers have a website that can be accessed on www.crollgroup.co.uk The home has a statement of purpose and service users guide available. Information about the home and most recent inspection report are available to residents/visitors in the lobby area of the home and copies. An information pack including a copy of the most recent inspection report is provided to each new resident. It was confirmed at the site visit that the current fees at the home are £520.00 to £635.00. There are additional charges for chiropody, hairdressing, personal items, newspapers/magazines, some transport costs and any privately arranged therapies. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was undertaken as part of a key inspection of Broadoaks and seven hours were spent at the home. Prior to this, the manager had completed an Annual Quality Assurance Assessment (AQAA) and returned it to the Commission. Information from this document was taken in account and is included in the report. Residents and staff were spoken with at the time of the site visit. Surveys were sent to the manager to distribute to residents, relatives and staff. Five relatives surveys, one resident survey and no staff surveys were returned to the Commission and information from the responses received is included in this report. Information was also received from a healthcare professional and a care manager, and from a GP spoken with at the site visit. A tour of the premises was undertaken and records, policies and procedures were sampled. Case tracking was undertaken in relation to some residents living at the home at that time and additional records were sampled for specific issues. Feedback on the inspection findings was given to the senior in charge at the time of the site visit and opportunity for discussion or clarification was given. The assistance of all those who participated in this inspection process is appreciated. What the service does well: All those spoken with or who provided information in surveys were satisfied with the care provided at Broadoaks. Residents said they like the food and the staff. Relatives felt welcome to visit and felt they were given good information about their family members. One survey commented “we were very fortunate to find Broadoaks, the standard of care is first class” and another said “ friendly staff who care about the welfare and well being of both resident and family”. A program of activities was available and many residents found these enjoyable. The premises are kept clean and odour free, and this was confirmed by the comments from residents and relatives. The manager and registered provider take time to seek the views of the people who use the service to help improve the experience. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Broadoaks DS0000018064.V347142.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 Broadoaks DS0000018064.V347142.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): 1, 2, 4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into Broadoaks are given sufficient information about the home to make an informed choice about where to live and will have their needs assessed to ensure that staff are able to meet these and provide appropriate care. EVIDENCE: The AQQA states that a brochure about the home is sent to all enquirers, followed up by a telephone call and a copy of the service user guide, statement of purpose. The most recent inspection report is sent to those who continue with their enquiry. Broadoaks have a statement of purpose and service user guide, which whilst not read as part of this inspection, were readily available in the home. Residents and relatives spoken with and comments from surveys received confirmed that they had been given information about the home. Some also confirmed they had been subsequently surveyed to gain their views on the admission process. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 9 Files for some of the more recently admitted residents were sampled. These show that written pre-admission assessments had been undertaken by the staff team at Broadoaks, as part of the pre admission process, to identify the person’s needs. There was evidence that family members have been involved in providing information on the person’s needs, likes and dislikes and on their life history. Information has also been obtained from other relevant sources so the team has all the information about the person to ensure that it can meet the prospective resident’s needs. On completion of the assessment, a staff member advised that the manager informs the person by telephone that the team at the home can meet their needs, rather than in writing as required. Further discussion suggested that letters are written but maintained at head office. Copies should be available on the residents’ file. The AQQA states that day visits are encouraged prior to admission so that the prospective resident can assess the quality of the care. A resident spoken said that they had not visited but that their relative had been able to visit for them and a relative spoken with confirmed this. Intermediate care is not provided at Broadoaks. Broadoaks DS0000018064.V347142.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, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Gaps in the recording of care management means that there may be times where the needs of residents are not always met. EVIDENCE: A sample of resident care management files was reviewed. A care plan was in place for each person but was not supported by a photograph to assist with identification. They contained some of the relevant information from the person’s assessment of needs such as dietary needs and preferences, however they did not reflect all areas of care required. Examples of this include having no detailed instructions for staff to follow on the person’s personal care needs on bathing, oral or nail care so that their wishes are respected, independence is promoted and staff can provide consistency of care practice. Potential risks for residents were not routinely assessed on all the files sampled. A file had a moving and handling assessment that was regularly reviewed, which is good practice. The person had mobility issues, yet there was no assessment and care plan relating to tissue viability where this was Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 11 clearly indicated to support preventative pressure area care, and staff spoken with did not know for sure, whether the person had a pressure relieving cushion and mattress. On another file the moving and handling assessment and risk assessment section, that identify for staff how to provide care in a safe way for the resident and themselves, was blank. The last inspection report identified an improvement to the regular weighing of residents and the AQQA stated that this occurred. However, records provided showed that this was not maintained and weights were not routinely recorded to evidence monitoring. Most of the care plans sampled had the signature of the resident or relative to confirm their involvement and agreement. All had been reviewed, which is positive, to ensure they remain accurate and up to date. Care notes were written regularly and were informative, and had information on care provided that was not identified in the person’s plan of care. The care notes, along with the bath book records, were kept separate from the person’s care plan and so did not support the use of care plans as working documents for staff in everyday practice. These issues were identified in the report of the last inspection of Broadoaks. The manager stated awareness in the AQQA that she needs to improve the information in residents’ care plans. Resident profiles contained information on their GP etc. Staff advised that no separate record is kept to show healthcare interventions to support monitoring and review. Instead this information is recorded within the pages of the daily care notes. A GP spoken with said “This is a good place, I would be happy to put my mum in here”. A district nurse commented in a survey that this home has always had a high standard. Survey information also showed that people were generally satisfied with the care and support provided to residents. Discussion with residents, relatives and staff and observation of practice during the site visit showed that resident privacy and dignity is respected at Broadoaks. This included in the way staff spoke to residents, how they responded to them and their needs and the opportunity for residents to retain management of their own finances or medication. A monitored dosage medication system is used and the medication administration records (MAR) were sampled. They were generally well maintained with the exception of the medication for one person on two occasions being recorded as having been administered while it was seen to remain in the blister. There were no photographs of residents with the MAR sheets to assist with identity. Records were maintained of medication received and returned. Safe storage was noted and a record kept of temperatures of the drug storage room to ensure they are appropriately maintained. A list of the sample signatures of staff deemed competent by the manager to administer medication was available. One resident was noted to administer their own medication and retain it in their room, which respects their abilities and supports independence. There was no risk assessment seen to ensure that this was safe for the person and for the other people living at the home. Broadoaks DS0000018064.V347142.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they will be provided with a range of activities, food and drinks to suit their preferences and needs and that they will be able to exercise choice and flexibility in their everyday routines. EVIDENCE: Broadoaks provides the services of activity co-ordinators for about ten hours each week and care staff confirmed that they support social activities for residents at other times. The activity co-ordinator spoken with advised that they had undertaken activity training a long time ago and had more recent training in moving and handling, protecting vulnerable people, first aid and seated exercise, which is positive, as is membership of the National Association for Providers of Activities for older people. Each activity co-ordinator keeps their own record of each resident’s abilities, interests and activities, providing two sets of records of the same area of care in addition to, and not clearly linked with, the person’s care plan. This does not present as a streamlined and most effective system to support monitoring of the person’s all round care needs and is again recommended to be reviewed. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 13 Overall, the records show a variety of activities are available to residents at the home including for example painting, playing bingo and glass and cake decorating. Care notes show that some residents go out with family and friends, and one survey suggested that residents would benefit from simple more local outings with the staff. Staff advised that residents in turn have opportunities for outings in the home’s minibus for example to the theatre or to the seaside for fish and chips and that seasonal activities also take place in house, for example a summer barbeque. Residents spoken with said they were happy with the opportunities provided and these included the hairdresser and going to church services. Residents said their visitors are welcomed. Visitors spoken with during the site visit confirmed this, as did the surveys received. Residents spoken with said they are able to exercise choice in everyday routines and choose what time they get up and go to bed or where and how to spend their time. Two residents who stayed in the lounge to eat lunch said that this was their own choice. Residents’ preferences and choices regarding food and drinks was also seen to be respected in everyday practice, including those identified in their initial needs assessment. One resident survey said “the food is very good and varied”. The record of food served contained good detail of both what was offered to residents and the amount eaten to support good nutrition monitoring. The cook stated that she was not following a written planned menu, but “a two week one in her head”. The cook was aware of residents’ dietary requirements and preferences and had clearly discussed these with residents. The record of food served showed a cooked breakfast on Sundays, and apart from the two days when a roast dinner was served, there was a main meal and an alternative each day. Ample food stocks were available. The cook advised that only fresh meat and fish, and the majority vegetables used are fresh. She added that all meals are home cooked, including the sampled apple pie which was delicious, and that residents are asked for their choices each day. Broadoaks DS0000018064.V347142.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had access to good systems to raise complaints and people feel confident to use it. Residents were generally safeguarded by the systems in place although some gaps in staff access to current information did not best protect residents. EVIDENCE: Information on the complaints procedure is available in the home and in the service user guide. It could advise people that they have the right to complain to their local social service department and include up to date contact information. Additionally it could make it clearer to people that the commission do not automatically investigate individual complaints and usually refer these back to the home. Neither the manager nor the Commission have received any complaints about Broadoaks since the last inspection. A form was available for logging complaints. A number of cards and a letter were available thanking the home for the service provided and included comments such as “thank you for looking after (resident) with such care and attention”. Surveys received from relatives, resident and professionals demonstrated that people knew how to make a complaint. Residents and relatives spoken with at the site visit confirmed that they would feel able to raise any concerns with the staff or the manager. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 15 The AQQA state that staff have received more training on safeguarding vulnerable people (pova) in the past 12 months, that they have an excellent understanding of these issues and the certificates are available for staff that have undertaken training. Of the training files sampled for five staff, only one contained a certificate confirming pova training and a staff member spoken with confirmed they had not yet had this training. The AQQA states that the manager has obtained a DVD training pack on the subject. One incident was raised as a safeguarding referral since the last inspection and related to concerns about a resident’s condition on admission to hospital. On investigation, it was identified that there was no case to answer and that good records were maintained and all care had been taken by the home. The policy and procedure on protecting vulnerable people was dated 2004 and would benefit from more up-to-date information on current multidisciplinary protocols and contact numbers. A whistleblowing procedure was available to support staff show they have any concerns and this advise them that they can contact the commission. Up-to-date contact details for the safeguarding team could also be included. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents of Broadoaks have a safe, clean and homely living environment that generally is suitable for their needs. EVIDENCE: All residents spoken with said that they were happy with the premises in general, and their own rooms. One resident said they had been able to bring their own ‘bits and pieces’, including their own chair. Staff confirmed the care plan information that a lockable facility is available to a resident who manages their own medication. Surveys and discussion with residents confirmed that some residents have telephones installed in their rooms. The communal rooms were comfortably furnished and homely. Bedrooms seen were personalised and fitted with door guards that allowed the doors to main safely open as residents wished but would operate safely in the event of a fire. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 17 The AQQA identifies improvement to the home in the last twelve months as including redecoration of a number of hallways and resident bedrooms, replacement of some carpets, new dining furniture and coffee tables for the lounge as well as upgrading of the television aerials so that digital signals can be received in the communal rooms and the residents’ own bedrooms. Improvements to the secure gardens are planned to make it more pleasurable and accessible to residents. All residents spoken with said that the home is always fresh and clean. All the relative comments received either directly or through surveys were particularly complimentary to the standard of cleanliness maintained at Broadoaks. The AQQA confirms clear policies and procedures are in place relating to infection control. Hygienic hand washing facilities were available. Hazardous items were safely stored and presented no risk to residents. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to be cared for by a motivated and reasonably stable staff group that offers them consistency of care. Recruitment and training procedures do not fully safeguard residents. EVIDENCE: Staff advised that there were no current care staff vacancies and that current staffing levels of one senior and two carers all day and one senior and one carers at night were adequate to meet the needs of the current seventeen residents. Staff advised more recently admitted residents were more independent. As noted at the last inspection, staffing levels needs to be continually monitored as in the afternoons and weekends there are reduced levels of housekeeping and kitchen staff and no housekeeping staff at weekends, which results in care staff having to manage all these tasks as well as caring for residents. One relative survey said that the home “at times seems a little short staffed”. While the AQQA confirms that seven staff had left the home’s employment in the past twelve months, recent rosters show very little recent use of agency staff, which promotes continuity of care for residents. All comments received relating to staff were positive and complimentary including that they are “reassuring and caring” and “care staff appear very willing and polite”. Observed staff interactions with residents were friendly and respectful and staff spoken with knew about residents . Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 19 The AQQA states that staff at Broadoaks are supported to achieve National Vocation Training (NVQ) and that five staff have achieved NVQ Level 3, one staff had started NVQ Level 2 and five staff had started NQV Level 3 training. Staff spoken with confirmed that this has progressed and more staff have now completed the training. Two staff recruitment files were reviewed. Both contained application, references and documents stating identity. Neither contained a photograph as required to confirm identity, nor did they have the required statement by the person of their physical and mental health. One file had evidence of povafirst check and criminal record bureau check, while the other did not. The rota for the day prior to the site visit show the use of an agency staff member. There was no profile or evidence available in the home that confirmed the person had had appropriate references, checks and training in place to safeguard residents. The provider uses a private induction recording system and the AQQA states that new staff are given a robust induction programme, as well as information including health and safety policies and the code of conduct required within the home. The manager also states that completing the induction and foundation training booklets within the recommended timescale is something that needs to be done better. Induction workbooks viewed showed that one had some entries and the other had almost no entries despite having been in post some weeks. A staff member confirmed that they had shadowed another staff member for their fist shift and them worked with an experienced carer for the first two weeks to help them to learn the job and get to know the residents and their needs. The manager states in the AQQA that certificates for staff training were on file in the home. Training files sampled varied in their content and did not evidence that staff are provided with all the basic and resident specific training needed to meet the needs of the people living at Broadoaks. The only certificate on one regular and permanent staff member’s training certificate file was for fire training. Other files showed a range of training for various staff including moving and handling, infection control, medication administration, first aid, food hygiene, Parkinson’s disease and dementia. The manager and deputy manager are trained to train others in moving and handling which provides the staff team with the support of routine access to this basic training. Staff advised that training on continence management is planned for the near future and most staff will attend. Staff spoken with advised of working as part of a team where levels of support and morale are high. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Broadoaks benefit from a generally sound management that has effective procedures for gaining the views of residents and relatives. Practices in the home generally protect residents, and promote a safe environment. EVIDENCE: The manager, who has been in post for some time at Broadoaks, was not duty at the time of the site visit. The AQQA advises that an experienced and capable deputy manager had been employed to support and assist the manager in the smooth running of the home, and who is currently undertaking the Registered Manager Award. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 21 The manager has systems in place to monitor the quality of the service. The senior in charge advised that an annual survey is sent out to residents and others to gather their views, although the report of the outcome of the last survey was not available in the home. One comment recorded was “ all members of staff are very helpful, caring and understanding”. Residents are also surveyed soon after admission for their views on the process. Reports are available that show that the required regular monthly visits to the home by a representative of the registered person were undertaken. Records show that residents and relatives meetings are held regularly as another way for residents to express their views and to have a say in the running of the home. The manager holds monies on behalf of residents and records are maintained in the home. Inspection of a random sample of individual resident’s monies showed that they were in order with receipts available and two signatures used to record transactions. Records are referred to throughout the body of this report and demonstrate some areas for development. These include ensuring that photographs are available of all residents as required by regulation. The AQQA does not offer information on the dates of the last review of policies and procedures. As noted earlier, it is recommended this is carried out on the whistleblowing and safeguarding policies and procedures. The AQAA confirms that all staff receive information and training on health and safety issues so that they may undertake their duties safely. Records were available that showed regular internal health and safety audits undertaken to ensure the safety and well-being of those who live and work there. These included for example checks of the fire alarm and fire equipment. Current inspection certificates relating to the fire alarm, portable appliances, passenger lift and gas were made available. A record of fire drills showed that not all night staff have been included. Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 22 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 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 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x 2 2 Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 13(4)&(5) Requirement So that residents are cared for safely and in a way that meets all of their care needs, care plans must identify all their individual assessed needs. Care documentation must provide staff with sufficient information to enable them to offer residents proper and consistent care and assistance that is supported by risk assessment. This includes areas identified in the report such as areas of personal care need, preventative pressure area care, medication management and moving and handling. This is an outstanding requirement from 01/10/05, 01/04/06 and 01/01/07 not fully met. 2. OP29 19, 17(2) Sch 2&4 So that residents are safeguarded, there must be evidence of robust and safe recruitment procedures and all the required records and documents must be available at all times for inspection. This includes for agency staff. DS0000018064.V347142.R01.S.doc Timescale for action 17/09/07 17/09/07 Broadoaks Version 5.2 Page 24 This is an outstanding requirement from the report of 31/10/06 3. OP30 18(1) a&c 13(5)&(6) Ensure that staff receive appropriate training to the work they perform. This refers to evidencing timely induction training and continuing basic training issues for all staff as well as training on specific conditions associated with the needs of people living at the home. This will ensure that staff have the competence, confidence and ability to meet resident’s care needs. Ensure that records required by regulation are maintained in the home. This includes a photograph of each resident and a record of any correspondence relating to each resident. 17/09/07 4. OP37 17 & Sch3 17/09/07 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 OP7 Good Practice Recommendations A review of the practice of keeping daily records separate from care plans should take place to make sure that care staff make full use of important information about residents. The medication recording sheets should note the reason why a resident’s medication has not been administered to them, to ensure their healthcare needs are met. 2. OP9 Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 25 3. OP9 The registered person should consider the provision of a photograph of residents is held with the medication records to enable correct identification. The practice of activity co-ordinators maintaining separate records should be reviewed to provide consistent and unified information on residents. To promote active choices for residents they should be offered a written menu that informs them of the choices that are available. So that staff have current information to safeguard residents the policy and procedure on protecting vulnerable people for abuse and whistleblowing should be reviewed and updated. To assist residents the registered person(s) should give consideration to the provision of grab rails in the corridor areas of the home. The level/designation/deployment of staff should be kept under review to be sure that they remain sufficient to meet residents needs at all times. 50 of care staff should be trained to NVQ level 2 or above. All staff should participate in drills to ensure their safety and that of residents. 4. OP12 5. OP15 6. OP18 7. OP19 8. OP27 8. 12. OP28 OP38 Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Broadoaks DS0000018064.V347142.R01.S.doc Version 5.2 Page 27 - 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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