CARE HOMES FOR OLDER PEOPLE
Broadpark House Belmont Road Ilfracombe Devon EX34 8DR Lead Inspector
Adele Adams Announced Inspection 17th October 2005 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 Broadpark House DS0000022141.V255013.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. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Broadpark House Address Belmont Road Ilfracombe Devon EX34 8DR 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) 01271 864752 NO FAX Mrs Elizabeth Emery Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (4), Old age, not falling within any other category (3) Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. To accommodate one person (named elsewhere) outside the categories of registration The maximum number of placements including that named individual will be 4 On the termination of the placement of the named person, the registered person will notify the Commission in writing and the particulars and conditions of this registration will revert back to the original categories of registration and number of service users 22nd February 2005 Date of last inspection Brief Description of the Service: Broadpark House is a large, detached, Georgian House, standing in its’ own grounds, in a residential area on the outskirts of Ilfracombe. Broadpark House is away from the road and is approached by its own level driveway, parking for visitors and staff is provided to the front of the home. The service provides twenty-four hour care and support for three older people and one younger adult – all with a history of learning disability and / or mental health problems. Sympathetic refurbishment work has been ongoing and continues, restoring the house in keeping with its’ original style, the rooms that have been completed are of a high quality. Local facilities and amenities are within walking distance of the home and are used by the ladies at Broadpark House. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has introduced “Key Standards “ to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain a full picture of the home it is recommended that all reports written within an inspection year (1st April to 31st March) be taken into consideration. This inspection was announced and took place between 10:00 and 13:10. During the inspection, the inspector spent time speaking with the ladies, the owner of the home, and deputy manager. The inspector toured part of the home and was invited into the rooms of three of the ladies living there. Time was also spent time reading documentation, which included: residents’ and staff records. A pre inspection questionnaire was completed by the home and provided before the inspection; residents and visitors comment cards were also provided; these together with the previous inspection report informed this inspection. What the service does well:
Broadpark House is registered as a care home for 4 residents and provides twenty-four hour care and support for three older people and one younger adult – all with a history of learning disability and / or mental health problems. The home is run and staffed by the owners Mr and Mrs Emery who have recently employed another person to support Mrs Emery in an assistant manager role. This has enabled the service to begin to work hard towards meeting the National Minimum Standards. Each of the ladies at Broadpark House have lived there for many years and are settled, the three ladies spoken with enjoy living there, have a good relationship with the owners and each other and access the local community and it facilities. The owner knows each of the ladies extremely well, has good relationships with local health services and described the improvements in the ladies health since living at Broadpark House. This inspection found the ladies enjoy living at Broadpark House, they say that they feel ‘well cared for and safe’ and that it is a ‘home from home’. Each lady has their own comfortable room. The ladies access the local and surrounding community and live varied lives as their individual abilities and wishes allow them.
Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
This inspection identified that improvements can be made in the following areas: The Statement of Purpose, Service User Guide and contract/ terms and conditions, need a few additional details adding to them to ensure that all the information detailed in the standards and regulations is available. Each lady living at the home needs to have a copy of the Statement of Purpose, Service User Guide and contract/ terms and conditions and have these explained to them or a family member on their behalf if needed. A medication policy needs to be put into place now that the improvements to medication have been made. The complaints policy/ procedure is to be altered to show a 28 day timescale is in place, which will make sure that people know what timeframe is being worked within. The service is to obtain the ‘Alerter’s Guide’, which will provide additional necessary and essential guidance to the No Secrets DVD and workbook. Quality Assurance methods could be improved by having a more formal approach ,which would show how, when and what improvements have been made and why this benefits the ladies at Broadpark House. Health and Safety matters must be attended to, this includes for example, areas of essential training such as infection control, manual handling, and fire safety, first aid and food hygiene.
Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 7 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. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 8 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 Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 6 The current information and contract nearly provides all of the information that should be available to help people and / or their families decide if Broadpark House is a suitable home for them. Intermediate care is not provided at Broadpark House. EVIDENCE: The inspector read the recently written Statement of Purpose, Service User Guide and Contract/ Terms and Conditions. These are clearly written in a language that clearly shows the service’s caring approach, a few small amendments are necessary and these were discussed with the owner and assistant manager. The owner and assistant manager confirmed that the ladies are not in possession of this information at present. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Each lady has an individual plan of care, which identifies their health, and social care needs, which state how these needs, are met; these are reviewed on a monthly basis. The medication systems now in place at Broadpark House have improved but medication training and a policy must be in place to underpin this. EVIDENCE: The inspector read each of the four ladies records, which clearly show what the individual health and social care needs are, how these are met and that they are reviewed monthly – at the moment the review does not include the signature of each lady. The 3 ladies spoken with are aware they have records at the home but are not aware of the content of them. Each record clearly shows health care needs, how these are met and the access to health care and health care services. The three ladies spoken to all describe how they can access medical care and one lady is attending hospital out patient appointments. The development of the records was discussed with the assistant manager and owner. New lockable storage has been obtained for the lady’s medication to be stored in. One lady at the home orders, collects, stores and takes her own medication – she discussed this with the inspector and showed the inspector the lockable
Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 11 container in which the medication is stored. The inspector read a signed statement showing the owner and lady’s acceptance of the self-medication arrangements. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13 The ladies at Broadpark House are able to maintain contact with family, friends and the local community. EVIDENCE: The inspector spoke with three of the four ladies living at Broadpark House, each told the inspector of what facilities they access and take part in the local community and of the visitors that come to see them, this confirmed what had been discussed with the owner and assistant manager. The inspector also saw evidence of this in the ladies care records. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 13 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 and 18 A complaints policy has been produced since the last inspection, this is almost complete and will be, once the timescale in which a complaint will be dealt with is included. The employment procedures do not fully protect the ladies from being at risk. EVIDENCE: The inspector read the complaints procedure and was shown the complaints book. The ladies have not yet seen this information. The three ladies spoken with all told the inspector that one of the good things about living at Broadpark House is that it makes them feel safe and that they know the owner and her family really well. The Adult Protection DVD ‘No Secrets’ has been obtained together with a workbook – the Alerter’s Guide is to be requested. The owner is waiting to hear from the CRB and was advised that is necessary for anyone working in the home- including the assistant manager to have one of these checks undertaken and to have 2 references before working at the home. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 14 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): 23 and 26 Broadpark House is spacious and clean providing a pleasant environment for ladies living there. EVIDENCE: The inspector saw the kitchen, lounge, hallway, the ladies rooms and bathrooms. All were clean and well cared for. The three ladies spoken with all like their rooms – which are referred to by their colour, each room is personalised showing each ladies taste and choice. Two ladies have their rooms and bathroom on the first floor and two ladies rooms and bathroom are on the second floor. Window openings are restricted. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 15 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): x To be inspected at the next inspection. EVIDENCE: Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 38 There is no system in place to show that the home is run in the best interests of the ladies living there. Health and safety at the home must be fully addressed to ensure that the ladies and staff live and work safely in a safe environment. EVIDENCE: The ladies spoken with by the inspector had been informed that an inspection was taking place and comment cards had been completed, the poster showing the time and date of the inspection was on display in the kitchen. The ladies advised the inspector that there are no meetings at the home and that they can talk to the owner at any time about any concerns. The inspector was advised that there is no development plan in place. The owner and assistant manager feel that seeking the views of visitors to the home would be a good place for them to start with quality monitoring. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 17 The inspector saw that an accident book has been introduced – the assistant manager is to find out about the suitability of the book and if a ‘standard’ accident book should be introduced. The inspector was shown that a fire procedures book has been introduced – this details when the alarm has sounded and the action taken. Domestic smoke detectors are in place in the home. A fire risk assessment for the building is not in place – each resident does have a room assessment, which addresses fire risks and evacuation issues. The home has fire extinguishers, which were maintained in January 2005. The fridge temperatures are now being recorded twice a day. The boiler and water heater were maintained on 16 June 2005. Two first aid boxes have been introduced in the kitchen but no training has been undertaken. Essential training such as moving and handling, food hygiene, first aid and fire safety has not been undertaken. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 18 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 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 18 x x x x 3 x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x x 1 x 1 Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation Reg 13(2) Timescale for action The registered person shall make 31/12/05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. This relates to the lack of a medication policy and medication training. Requirement 2 OP18 Schedule 2 Information and documents in respect of persons working at a care home. 6. A criminal record certificate. This relates to finding that one member of staff had not had a CRB check and did not have 2 references on file. If the registered provider is an individual, he shall undertake; from time to time such training as is appropriate to ensure that he has the experience and skills necessary for carrying on the care home. 30/11/05 3 OP38 Reg 10 (2) (b) Reg 12 (1) 31/12/05 Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 20 The registered person shall ensure that the care home is conducted so as – (a) to promote and make proper provision for the health and welfare of service users This relates to undertaking necessary health and safety training. 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 3 4 Refer to Standard OP1 OP2 OP16 OP33 Good Practice Recommendations The Statement of Purpose and Service User Guide must contain all of the information in the standard. The contract/ terms and conditions must contain all of the information in the standard. The complaints procedure should provide assurance that complaints will be responded to within 28 days. The registered person should have an effective quality assurance and quality monitoring system in place. Broadpark House DS0000022141.V255013.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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