Inspection on 18/05/06 for Broadpark House

This inspection was carried out on 18th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broadpark House 26/07/07

Broadpark House 18/01/07

Broadpark House 06/03/06

Broadpark House 17/10/05

Broadpark House 22/02/05

Broadpark House 30/09/04

Broadpark House 18/03/04

Broadpark House 20/11/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Broadpark House Belmont Road Ilfracombe Devon EX34 8DR Lead Inspector Jo Walsh Key Inspection 18th May 2006 11:00 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.V290593.R01.S.doc Version 5.1 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.V290593.R01.S.doc Version 5.1 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.V290593.R01.S.doc Version 5.1 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 6th March 2006 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. The fee range from £250 to £363. A copy of this report will be placed on the residents’ notice board in the kitchen. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, meaning the home were not made aware that the inspection was to take place. The inspection was conducted over 4 hours and looked at key National Minimum standards. Time was spent talking to the three residents, as well as the homeowner and her one member of staff. Since the last inspection one resident has died. A tour of the premises was completed and some key documents were viewed and discussed. The registered provider and this completed an inspection questionnaire together with the previous inspection reports were also used to help inform how well the service is meeting the needs of the residents. What the service does well: What has improved since the last inspection? Plans of care were available for inspection. Previously these had been taken away to be updated and so were not available for inspection during the last inspection visit. The plans detail clearly individuals’ assessed personal and health care needs, together with some risk assessments; these ensure that the home provides care in a consistent way. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 6 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. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 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 Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Current residents can be assured that their needs have been assessed and reviewed to ensure the home can meet their needs. EVIDENCE: All residents’ care plans were viewed as part of the inspection process and each had a copy of the statement of terms and conditions, which means they are made aware of their rights and responsibilities. The owner stated that these were read through with each resident once they had been developed. The home has not had any new residents for over 11 years, so it is difficult to fully assess whether a full assessment was completed prior to admission. Any new resident will be offered the opportunity to visit prior to moving in to ensure they feel comfortable in a smaller home and get on with the other three residents. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” The residents’ health, personal and social care are well met. Residents who self medicate are not fully protected. Residents can be assured they will be treated with respect and dignity and this includes at the time of their death. EVIDENCE: Plans of care were viewed and discussed with both the owner and residents they concern. During the previous inspection care plans were not available, as they had been taken away for updating. Plans detail individuals’ personal and health care needs and state what social activities each individual enjoys. The health care is clearly set out and details any appointment to see GP’S or other health care professions. All three residents spoken to felt that their health care needs were always met in a timely fashion, that they were well cared for and saw their GP when needed. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 10 Only one resident currently takes medication and they do this independently. The home have a written statement signed by this individual to say they consent to self medicating, but there was no risk assessment in place or system of checking on a regular basis that this individual was taking their medication correctly. This risk assessment and review of the individuals capacity to continue to self medicate must be put into place to ensure that they remain safeguarded from the risk of over medicating or forgetting to take medication. A policy is in place for medications managed by the home and a secure place is available to store them. They do not currently manage anyone’s medications. Residents confirmed that they are treated with respect and their rights to privacy were upheld. Examples given to evidence this were that people knock on their bedroom door before entering, residents are referred to by their preferred name and care and support is always provided in private. The resident who has recently died was enabled to remain in the home, which had been her home for many years. The individual’s family had written a letter to the owner saying how good they believed the care to be. The owner stated that they remained in regular contact with the family and they had access to visit the individual at any time they wished. The home is be to commended for enabling this individual to remain in her home for her final days as due to failing health the care needs had increased significantly. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 11 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): 12,13,14,15 “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Service users can be confident that that they will be able to maintain contact with family and friends, access the local community and helped to exercise choice and control over their lives. EVIDENCE: Care plans detail what activities each individual enjoys participating in and residents confirmed that they are enabled to take part in activities both in and outside the home. Two residents stated they enjoy attending a local day centre to participate in craft and meet up with different people. One resident who has a sight impairment is enabled to go to a local group for people with sight impairment. Other activities include attending a local tea dance, bingo sessions and accessing the local amenities. Residents are enabled to access these activities either by the owner providing transport or arranging taxis. One resident is able to access the local community independently. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 12 All three residents confirmed they have a good range of activities to occupy them. One resident stated they enjoyed helping out with chores and doing some shopping for the home or other residents. Residents said they were happy with their daily routines and could choose when to get up go to bed and where they spent their time. Two residents spend time together and enjoy each other’s company. One resident stated ‘you couldn’t wish for better care, it’s my home and I love it here, I feel really settled and happy’. All three residents confirmed that they enjoyed the meals offered, that there was a good choice and variety. One commented that ‘The meals are really nice, I really enjoy them’. One resident when asked said they were not sure what was being given for their mid day meal, but that they always enjoyed everything. The home could consider having a menu board or menu plan available for residents so they are aware beforehand what meals are being offered. The owner has provided support for this group of residents for many years so is well aware of what their likes and dislikes are. Residents are enabled to have visitors and friends to visit the home, the owner is happy for them to stay for meals or overnight at no charge. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 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): 16,18 “Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service.” Residents can be confident that complaints and concerns will be taken seriously and dealt with. The employment procedures and lack of recording in dealing with residents’ finances do not fully protect the residents from being at risk. EVIDENCE: The home has a written complaints procedure and residents said that they could talk to the owner about any issues they may have. The person employed still does not have a completed CRB, as they have experienced difficulties in accessing an umbrella body to do this. During the inspection process an umbrella body was found and the employee was able to give their details to ensure a CRB and POVA check is in the process of being completed. The Owner was also advised that she must ensure two references are obtained and held on file as well as copies of the individual’s identification to ensure that residents are fully protected by robust procedures that fully check any persons working in the home. The owner has agreed to get this done as a matter of urgency, but gave assurances that the one person she employs has been a friend and care worker for many years. The home have obtained a copy of the Devon County Council Alerters guide would benefit from some protection of vulnerable adults training. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 14 The home does not keep records of financial transactions completed on behalf of residents. This does not protect either residents or the home from possible abuse, or allegations of abuse. The owner was advised that she must keep a record and audit trail of all financial transactions, even if it is only to ensure residents who have control over their personal allowance, sign to say they have received it. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 15 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): 19,20,23,24,26 “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” The home is suitable for its stated purpose and provides a clean comfortable and homely environment for residents to live in. EVIDENCE: During this inspection the main lounge, kitchen/diner and all residents’ bedrooms were viewed. All areas of the home looked at were very clean, furnished and decorated to a high standard and provide a pleasant homely environment. The residents spoken to say they liked their rooms, which they had personalised and decorated to their own tastes. The owner and her husband live in the home and it is very much a family based home. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 16 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): 27,28,29,30 “Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service.” The home cannot ensure the safety of the residents due to poor recruitment practice and lack of training. EVIDENCE: The home is run mainly by the owner and her husband who provide much of the 24-hour care and support. At present three of the residents are fairly independent and having one person available is appropriate to their needs. The home does not provide waking night cover and this is not currently needed for the resident group living at the home. The owner has not completed NVQ training or any of the core areas that would ensure residents’ safety. These include basic food hygiene, first aid, moving and handling, fire training and infection control. Time was spent during the inspection process discussing why these key areas of training are essential and how they might be achieved. The one member of staff employed also needs to complete this training, to ensure they can complete their role in a safe manner that ensures the safety of the residents. The recruitment procedures do not ensure the protection of residents; this has already been detailed in the previous section and advice given as to how this can be achieved. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 17 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): 31,33,35,38 “Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service.” The owner is unable to demonstrate her competence to fulfil her role safely. There were no accounting procedures available to ensure resident’s monies are safeguarded. The health, safety and welfare of residents cannot be fully promoted or protected, as key training has not been completed. EVIDENCE: Although the owner Mrs Emery has no formal training in management or care, she has been offering care and support to the resident group for 30 years. She Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 18 does not intend to offer care to any other group of residents, but feels she would like to continue with her three remaining ladies for as long as she can. As the home is run within a family based environment a referral has been made to the local adult placement scheme, which provided support and monitoring of these types of placements. Training in key areas as already been highlighted in the previous section, must still be implemented for any persons working with the resident group to ensure that care can be provided safely for both residents and staff. The home does not have a written annual development plan or quality assurance system in place that seeks the views of residents to help improve the quality of care provided. The pre inspection questionnaire submitted prior to the inspection highlights that the home ensures a safe environment by having the central heating and electrical systems checked, risk assessing for hot water and possible risk of burns from hot surfaces. The home keeps records of any accidents and has a procedure for RIDDOR and the safe storage and disposal of any hazardous substances. The home last had their fire equipment tested by the manufacturers on the 20.1.06 and they state that they do weekly checks on the fire alarm. They have not had training in fire safety and should ensure they do this. The home had not informed the Commission prior to the inspection visit, that one of their residents had died. The home were reminded that under regulation 37 they must ensure that they inform the Commission of any significant event that effects the welfare of its residents. Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 19 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 4 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 1 3 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 X X 2 Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation Reg 13(2) Timescale for action The registered person shall make 30/05/06 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. Risk assessments for any persons self medicating must also be implemented (Previous date set for compliance 31/12/05) 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. (Previous date set for compliance 30/11/05 and 30/05/06) 30/07/06 Broadpark House DS0000022141.V290593.R01.S.doc Version 5.1 Page 21 3 OP38 10(2b) 12 (1) 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. (Previous date set for compliance 31/12/06) The home must keep a record of all financial transactions in respect of individual residents The home must ensure that it informs the commission of any significant event such as death, illness or serious accident involving a resident. 31/08/06 4 5 OP18 OP37 17 37 30/06/06 30/06/06 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. 5 6 Refer to Standard OP1 OP33 OP18 OP29 OP30 OP38 Good Practice Recommendations The Statement of Purpose and Service User Guide must contain all of the information in the standard. The registered person should have an effective quality assurance and quality monitoring system in place. The home should ensure that staff has training in the protection of vulnerable adults. The home should ensure it has a copy of the code of conduct and practice set out by the General Social Care council. The home should ensure that staff has a minimum of 3 days paid training per year and that these include core skill areas. The home should ensure that all staff complete fire training. 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