CARE HOME ADULTS 18-65
Broadstone Close Residential Care Home 1 & 2 Broadstone Close Oakwood Derby DE21 B4P Lead Inspector
Unannounced Inspection 29th November 2005 03:00 Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 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 Broadstone Close Residential Care Home DS0000001967.V269392.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 Adults 18-65. 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. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Broadstone Close Residential Care Home Address 1 & 2 Broadstone Close Oakwood Derby DE21 B4P 01332 544557 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) Royal Mencap (Housing & Support Services) Catherine Francis Measures Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Broadstone Close is owned by Mencap. The accommodation comprises of two houses, which provide personal care and accommodation for up to 9 people in the category of adults with a learning disability aged between 18 and 65 years of age. Broadstone Close is located just off Wood road, in Chaddensden. It is close to local amenities. A car park in available at the front of the premises. Both houses have an accessible garden, which is segregated with a garden fence. The service users can access the patio area, which links both the houses. Each house is run independently in accordance with service users needs. Broadstone Close provides all single bedrooms. Both houses reflect the style of a family home. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 3pm. The visit lasted 3 hours, and was the second inspection of the home this year. The inspector checked the previous requirements and recommendations made in the previous inspection report, and checked the key areas that were required to be assessed in a 12-month period. She examined care files and associated documents, and spent time speaking with staff members and service users. A tour of both houses was undertaken and the health and safety records and checks of the building were examined. Time was spent observing service user and staff interaction. The Manager was on duty and assisted the inspector with the inspection. What the service does well: What has improved since the last inspection? What they could do better:
The staff team must improve their medication practices and ensure that two people check and countersign handwritten instructions. This is to ensure that the medication instructions are accurate. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 6 The Registered Provider should update their application form so that it requests a full employment history in accordance with the legislation. 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. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed on this occasion as they were assessed during the previous inspection visit Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The staff team have a good understanding of the service users support needs. This is evident from the positive relationships, which have been formed between the staff and the service users. EVIDENCE: The inspector examined two care plans, and this standard continues to be met as the plans cover all of the required areas. Some of the plans are at different stages in terms of the level of detail and the additional topics that have been completed in relation to service users aspirations. There was evidence in both files that the service users have been involved in the development of their plan as service users are enabled to make a statement about their plan and they sign in agreement. Service users showed a good understanding of their plan in their discussions with the inspector. The inspector spoke with all of the service users during the inspection and many positive comments were received about living in this home and the quality of the support they receive. Service users comments included; the staff are “smashing”, “its nice living here”. Service users confirmed that they are always treated us with dignity and respect,
Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 10 The observations of the interactions between the staff and the service users confirmed that positive working relationships have been developed. The staff team continue to enable the service users to be independent and consult them on all aspects of daily living. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed on this occasion as they were assessed during the previous inspection visit Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Improvements are required to the medication practices in order to safeguard service users. EVIDENCE: The management of medication has not improved in response to the requirement made in the previous inspection report. The staff team in both houses continue to write handwritten medication instructions onto the Medication Administration Record (Mar chart) without two staff members checking and signing to ensure the instructions are accurate. This was discussed at the time of the inspection and the staff team are aware that this should be done. All other aspects of the medication procedures were satisfactory. The inspector was informed that the signature sample sheet was currently being updated. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Satisfactory complaints and adult protection procedures are in place in order to safeguard service users. EVIDENCE: An accessible complaints procedure and recording system is in place. From discussions with the service users it was evident that they were aware of the procedure and informed the inspector that they would not hesitate to raise any concerns they had with the staff or the Registered Manager. The inspector was informed that no complaints have been received since the previous inspection. A Vulnerable Adults policy was in place, which links in with the Derbyshire Adult Protection procedures. All of the staff team have undertaken some form of abuse training either by attending courses or through their NVQ training. There have been no incidents at the home this year. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29, and 30 Service users benefit from well-furnished and maintained houses that create a homely environment. EVIDENCE: Both of the houses are decorated to a good standard and were free from any odours. The inspector was informed that the communal areas have been redecorated and service users confirmed that they choose the colour scheme. The inspector was invited to view some of the service users bedrooms. The bedrooms were personalised with service users own belongings, and had the appropriate fixtures and fittings available. All communal and bathroom areas were well maintained and decorated to reflect a homely environment. The service users in one of the houses have put the Christmas tree up in preparation for Christmas. All of the repairs that were identified in the previous inspection report have been addressed. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35 and 36 The recruitment procedures do not fully safeguard residents from potential risk. An experienced and trained staff team supports the service users. EVIDENCE: The inspector examined three staff files, one of these was for a new employee. All files contained all of the required documentation and were in good order. However the application form used by the organisation only requests an employment history of 20 years instead of a full employment history as required by the amended Care Home Regulations 2003. There was evidence in the staff files to confirm that they receive regular supervision. The inspector spoke with the relief staff member who confirmed that he now has access to supervision all of the mandatory training. The inspector and the Registered Manager discussed the status of the staff team in relation to achieving National Vocational Qualification (NVQ). The inspector was informed that currently there is 5 staff members who have completed an NVQ level 3 and 4 staff members working towards this qualification. The Registered Manager has also completed the NVQ level 4 in Care and Management. The home has therefore met the target of having at least 50 of its staff team qualified to the required level, or undertaking training by this date. The inspector examined the training records and all staff members have undertaken the required mandatory training.
Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, and 42 The systems for service user consultation are good with a variety of evidence that indicates that service users views are both sought and acted upon. EVIDENCE: The aims and objectives of the home are to enable and involve the service users in all aspects of the running of the home. The observations made at the time of the inspection confirmed that staff practices are in accordance with these objectives. Service users confirmed that they are consulted at all times about the daily running of their home and the routines are service user led. The service users have access to meetings, which are facilitated by an Advocate were they discuss living at the home and raise any issues they may have, which are then reported back to the Registered Manager. The service users also receive a quality assurance questionnaire from the responsible provider asking them their opinions on aspects of living at the home. The service users sign consultation forms detailing their opinions on the issues being discussed and the outcomes. Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 17 The inspector checked some of the health and safety systems in place at the home. All of the staff team had received updated Fire training. The gas and electrical installations certificates were in date. Checks on the water temperatures and checks required to prevent legionella were undertaken on 10/10/05. The electrical appliances were PAT tested in July 2005. The required insurance cover is in place and up to date. The temperature of the fridge and freezers were also up to date. Broadstone Close Residential Care Home DS0000001967.V269392.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 x Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 x Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 19 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 YA20 Regulation 13 (2) 17 (1) (a) Requirement The Registered Person must ensure that handwritten instructions recorded on a Medication Administration record (MAR chart) are countersigned by two people. (Previous timescales not met since 31/10/04 not met.) The Registered Persons must ensure that the application form requests an applicant’s full employment history. Timescale for action 01/02/06 2 YA34 19 (1) (b) (i) 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Broadstone Close Residential Care Home DS0000001967.V269392.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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