Inspection on 12/01/06 for Broadwater Lodge

This inspection was carried out on 12th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broadwater Lodge 19/04/07

Broadwater Lodge 25/05/06

Broadwater Lodge 20/06/05

Broadwater Lodge 16/11/04

Broadwater Lodge 25/05/04

Broadwater Lodge 24/04/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

CARE HOMES FOR OLDER PEOPLE Broadwater Lodge Higham Road Tottenham London N17 6NN Lead Inspector Karen Malcolm Unannounced Inspection 08:45 12 January 2006 th 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 Broadwater Lodge DS0000033332.V265255.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. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadwater Lodge Address Higham Road Tottenham London N17 6NN 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) 020 8808 6070 020 8493 0066 London Borough of Haringey Miss Sylvia Anne Beaumont Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45) of places Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide intermediate care to a maximum of 9 of the 45 service users of either gender who are aged 65 years or older. Accommodation for this service is to be restricted to the dedicated unit on the ground floor. The unit must have a team of staff specifically dedicated to it. Any individual service user`s stay within the unit should not be any longer than six weeks. The provider must undertake a programme of measures that will achieve full compliance with National Minimum Standards for Older People by 1 April 2005 Standards 19 to 26 - Environment, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by 1st April 2005. The provider must ensure that the home complies with all requirements contained in the relevant Health and Safety legislation by 1st April 2005. and further must undertake a programme of measures that will achieve full compliance with National Minumum Standards for Older People - Standard 38 - Safe Working Practices, or those equivalent Standards that may be published at the time, as required by Regulation 23(1)(a); 23(2)(a to p); 23(4)(c) and Regulation 16(2)(c)(g)(j)(k) - by 1st April 2005, in order to promote the health and safety needs of service users. 20th June 2005 2. 3. Date of last inspection Brief Description of the Service: Broadwater Lodge is a purpose built home run by the London Borough of Haringey, providing care for up to 47 people who are elderly. Some residents have additional physical disabilities and mental health needs associated with ageing. The home is on three floors, with two living units on each floor. One unit provides care tailored to the needs of Elders from the Caribbean Community, and one unit has been refurbished to provide nine intermediate care beds. The stated aims of the home are to enhance the dignity, self-respect and individuality of each resident. In addition to providing care for its residents, and access to medical professionals as required. activities are provided by an activities co-ordinator. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over one day. The duration of the inspection was approximately three half hours. The registered manager assisted the inspector throughout the inspection. The staff on duty were two assistant managers, seven carers, one cook, one assistant cook and four support workers that included the laundry person. The inspection involved sampling a number of care plans, records and a tour of the building and observing the interaction between staff and service users, which was friendly and caring. The manager and all staff the inspector met were very open and helpful throughout the inspection. A present the home supports thirty-one service users, seven of which are diabetic. At present there are five vacancies and the rehabilitation unit is housing the service users who originally reside in Rowan unit, as this unit is being refurnished as part of the home’s major refurbishment programme that is still in process. During the tour of the building, it was evident that many of the units have been completely refurnished, redecorated with brand new kitchenette and flooring. However, there still remains some major works being carried out on the external part of the building. Prior to this inspection the inspector received a copy of the home’s PreInspection report and comment cards from service users and other professionals. Twenty-eight service users and one health and social care professionals comment cards were received. Feedback recorded was generally very positive. What the service does well: The home is warm and welcoming providing the service users with a good support system. The home also supports service users from varying different ethnic groups; one unit within the home is dedicated to support service users from an Afro Caribbean background. The team supporting service users compliments the users group and are skilled, dedicated and experienced. Service users spoken to state that they are treated with respect and their rights to privacy are upheld. Care plans in place were found to be comprehensive and clear. Care staff ensure that individual’s care and health needs are supported appropriately. The home’s policies and procedures are in place. The home encourages and supports service users to maintain contact with family and friends in the community. The service users opportunity to have choices and control over their lives are integral to the operation of the home. The menus offer a good choice of food and individual preferences are catered for within this it includes meeting individuals cultural diversity and dietary needs. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: This inspection has identified nine areas of improvement and two recommendations. Three of the areas of improvement from the previous inspection have been restated in this report. One Immediate Requirement notice was issued, relating to medication procedures. The registered manager prior to this report being completed has addressed immediate requirement. Following on from this, it is therefore required that the registered person submit an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters. The action plan must describe how the registered person ensures: • • • • • • That care staff wash their hands prior to administering medication to service users and any service users who refuses their medication constantly must be reviewed with their GP. That care staff administering medication to service users must sign the Medication Administration Records (MAR) charts after administering the medication and not before. That an annual environmental and fire risk assessments are to be completed and reviewed annually That following on from a fall from a service user a thorough risk assessment must be completed. Records of falls must be submitted to the Commission without delay. Visitors are able to enter the home safely during the external works being carried out Monthly summaries must be completed with information relating to the individual’s risks and goals changes. The two recommendations stated in the table at the back of the report are deemed a good practice. The requirements made at the last inspection that have not yet been met and have been restated in this report, with a new timescale of compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescales given the last inspection. The date in bold type relates to the new Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 7 timescale. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. 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. Broadwater Lodge DS0000033332.V265255.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 Broadwater Lodge DS0000033332.V265255.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 Prospective service users are have the information they need to make a choice about where they would like to live through the publication in place. EVIDENCE: Standard 2 was assessed at the previous inspection and met. Therefore this Standard was not assessed at this inspection. The registered manager gave the inspector a copy of the newly devised Social Services Information for Older People’s pack. That included a number of factual documents and information pertaining to older people using or finding out about what is provided by their local authority. The manager stated that the pack is slightly adapted for each service. The Statement of Purpose and service user guide for the home was included in the pack the inspector received. The home’s Statement of Purpose and service user guide examined were comprehensive and clear. At the previous inspection it was required that the registered person amended the Statement of Purpose to include a section on • A list of all room sizes to including the lounge and the kitchen etc.… Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 10 • Qualification of the registered provider • Gender range of service users who reside in the home Upon reading the document it was evident that the areas such as the room sizes and gender range of the service users who reside in the home were addressed. However, the qualification of the registered provider was not addressed. Therefore this requirement has been partially met and restated in this report. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8&9 Service users care plans are in place, addressing individual’s health and care needs. However, risk assessments and monthly summaries are not consistently up-dated following a change to a service user’s care needs. Therefore service users can be assured that their care needs are monitored appropriately. Service users are confident that their medication is appropriately safeguarded and maintained by the home. However, this is not consistently monitored, therefore service users can be potentially placed at harm if not reviewed regularly by the home. EVIDENCE: Standards 10 & 11 were assessed at the previous inspection and met. Therefore these Standards were not assessed at this inspection. Since the previous inspection a number of Regulation 37 forms have been submitted to the regarding service users being admitted into hospital or an incident happening. The falls records were examined. It was evident that records of falls are recorded, however, it was evident that no monitoring or risk assessments for individual who fall frequently are up-dated or the information recorded did not clearly indicate how the service user’s care needs is or are to be managed. The other areas of concern are that no records of Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 12 individuals’ falls have been submitted to the Commission. Monthly summaries are completed however they do not reflect fully on what changes or the individual on a monthly basis has achieved improvements. This was discussed at length with the registered manager and assistant managers during the feedback session. The medication administration records charts were examined. The assistant manager stated that the service users were too frail to administer their own medication. The records for the receipt, administration and disposal of medicines were generally satisfactory at the time of the visit. Apart of the inspection process involved the inspector observing one of the assistant managers administering medication to service users. The assistant manager interacted well with the service users, however, a major concern was that the assistant manager did not wash their hands prior to administering medication and the Medication Administration Records (MAR) chart were signed before the medication was administered to service users. This was discussed with the assistant manager at the time of the observation. It was also evident that one specific service user’s medication for Queltapine stated two tablets to be taken twice a day. The ‘two’ on the MAR chart was crossed out and ‘one’ was written in pen. The service user’s surname was also crossed out and changed to another surname. It was apparent from the discussion with the assistant manager that the service user whose original name was on the MAR chart, had the same medication as the service user whose name was now recorded in pen. However, the original service user, medication had been discontinued by the GP. The assistant manager stated that the pharmacist had supplied the discontinued medication this month, but forgot to supply the other service user their medication. Both service users have the same first names. An Immediate Requirement was issued for the registered manager to rectify this immediately. Roles and responsibilities of the assistant managers were discussed. It was apparent that only the assistant managers administer medication on each shift. The manager also stated that a number of carers were deemed competent to administer medication, but solely the assistant manager and not the care staff working on the different units currently conducts this task. This was concerning. It was the inspector’s view that the assistant managers’ roles and responsibilities are overloaded and must be reviewed. The home supports three service users who have been diagnosed with diabetes. It was evident that although the home follows the individuals health care routines, it was evident from the information recorded that the information recorded was not comprehensive and addressing all the care needs of the individual in the home. This was discussed with the registered manager and the assistant managers. It was suggested that the format in place should be reviewed. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 13 Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 14 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): 15 The meals in the home offer choices and variety, and cater for special and cultural dietary needs. EVIDENCE: Standards 12 & 13 were assessed at the previous inspection and met. Therefore these Standards were not assessed at this inspection. The newly refurnished and redecorated kitchen is in operation. Menus displayed in the kitchenette showed a varied diet on offer, and that individual preferences are catered for, and one service user confirmed this. The menus are on a three-week rotation, and have been redrafted in consultation with service users. The meals are prepared in the large kitchen area and then transferred into trolleys for each unit. Meals provided on the day seemed nutritious, wholesome and balanced. One of the units is dedicated to service users from an Afro-Caribbean background. It was evident from the menu plan that service users catering needs are met by the home also. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to. Service users are protected with the knowledge that staff are well trained and understand the procedures with regards to abuse. EVIDENCE: Standard 18 was assessed at the previous inspection and met. Therefore this Standard was not assessed at this inspection. The complaint book is in place. Three complaints were recorded. It was evident that the registered manager had addressed each complaint appropriately, however, it was recommended that the present format could be improve. The inspector shared a number of samples of how the complaint/s format could be improved during the feedback session with the registered manager and the assistant managers. Records indicate there have been two referrals to the local adult protection team and strategy meetings held. It was evident, however the local adult protection unit had not fully addressed one of the referrals made regarding an alleged abuse. The manager is in discussion with the adult protection coordinator regarding this. It was evident from the paperwork seen that the manager and service manager had completed a thorough investigation into the matter. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home is appropriately decorated, therefore providing the service users with a warm and inviting pleasant environment they can call home. EVIDENCE: The Broadwater Lodge is divided into smaller unit area, these are: - Hibiscus, Holly, Primrose, Rowan lower, Rowan ground and Main Rowan. Each unit has dining/kitchen/lounge areas, bath/shower & toilet rooms and single bedrooms. Hibiscus is a specialist unit supporting service users from an Afro Caribbean background. At the previous inspection a number of areas regarding maintenance needed addressing. It was evident as part of the major works programme these were addressed, however, the external part of the home is still under-going refurbishment. A number of units within the home at the time of this inspection were completed. During the tour of the home a number of service users and staff expressed their views on how comfortable and inviting the new layout and presentation of the home was. The only area of concern raised with Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 17 the manager related to the outside of the building, regarding the entrance to the home. There were no clear signage positioned in the grounds indicating or helping visitors’ to know where and how to enter the home safely. The laundry room was examined. It was evident that the registered manager had obtained appropriate soap containers for the washing machine. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 A good skill mix of care staff supports the service users, therefore ensuring at all times suitably competent and experienced staff are working in the home. EVIDENCE: The staff team consists of the manager, assistant mangers, domestic carers, cooks and assistant cooks, administrator, handy person and laundry staff. On duty were the manager, seven care staff, the cook, one assistant cook, four domestic, the laundry assistant, three assistant managers and, the administrator. The rota shown clearly indicated that the shifts are adequately managed. The ethnic make-up of the staff team is very varied, matching the service user group being supported. The manager informed the inspector that since the previous inspection, there have been thirteen new starters since September 2005. The roles and responsibilities of the manager and assistant manager were discussed and it is the inspector views that the senior teams’ roles and responsibilities are overloaded and must be reviewed. A sample number of personnel records were examined. All records examined had in place the correct records as set out in and stated in Regulation 19. It was also evident that the care staff whom had recently started employment were supported appropriately as evidence indicated that supervisions and induction programmes were in place and signed and dated by both parties. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 19 A copy of the up-dated training manual was submitted to the Commission along with the Pre-Inspection report. It was evident that the timetable for training runs up until June 2006. Covering training such as Fire awareness, inductions and food & Hygiene Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Service users health and safety are being regularly reviewed and monitored. However, areas such as the environmental and fire risk assessments in place to ensure that service users are fully protected with regards to health and safety within the home. EVIDENCE: Standards 33 & 35 have been assessed at the previous inspection and met. Therefore these standards were not assessed at this inspection. Part of the inspection process included the inspector completing a fire risk assessment whilst touring the building. The purpose of the fire risk assessment was discussed with the manager. It was identified through the fire risk assessment that there were a number of good practices and some areas of concern. All the fire extinguishers are in place, fire drills and checks are completed and the means of escape is clear. All fire doors have magnetic door closures in place. It is advised that the manager must complete a Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 21 environmental and fire risk assessment which is reviewed and monitored annually. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 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 2 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 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 OP9 Regulation 13(2) Requirement The registered person must contact the pharmacist and obtain the correct medication dose for the specific service user whose medication is incorrect. This must be rectified immediately and evidence that this has been done to be submitted in an action plan to the CSCI by Friday 13th January 2006. Immediate Requirment The registered person must amended the homes Statement of Purpose to include a section on the qualification of the registered provider. Timescale of 30/08/05 was partally met The registered person must ensure that any changes in care needs such as falls, must be updated accordingly on the service user’s care plans and risk assessments. Detailing the health concerns and what measures have been put in place. Evidence is to be recorded on the individuals care plan. DS0000033332.V265255.R01.S.doc Timescale for action 13/01/06 2. OP1 4 Sch 1.2 20/03/06 3. OP8 17(1a) Sch 3(3m) 20/03/06 Broadwater Lodge Version 5.0 Page 24 4. OP8 17 Sch3(m) 5. OP19 13(4) 6. OP38 13(4) 7. OP9 13(2)(4) 8. OP9 13(2) Timescale of 16/09/05 not met. The registered person must ensure that all service users who are diagnosed with diabetes have in place on their care plan/s comprehensive risk assessment, which addresses individual’s dietary needs, care needs and support. Evidence of this is to remain on file. Timescale of 16/09/05 not met. The registered person must have in place clear signage that helps visitors’ to the home enter the building safely. The registered person must complete environmental risk assessment that includes a fire risk assessment. This is to be reivewed annually. The registered person must ensure all care staff wash their hands prior to administering medication to service users. The registered person must ensure that the staff sign the Medication Administration Records (MAR) chart is sign after medication is given and not before. The registered person must ensure that service user whom persistently refuses their medication when administered has an appointment made with the GP to review their medication given. Evidence of this must be available for inspection. The registered person must notify the Commission without delay of any occurrence, which adversely affects the well-being or safety of any service user. (This includes falls of service DS0000033332.V265255.R01.S.doc 20/03/06 28/02/05 30/03/06 20/02/06 28/02/06 9. OP8 37 28/02/06 Broadwater Lodge Version 5.0 Page 25 10. OP8 17 users.) The registered person must ensure that the monthly summaries address all the areas of risks and goals set for individuals’, showing clearly whether or not a risk or a goal has been achieved. 20/03/06 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. Refer to Standard OP27 OP8 Good Practice Recommendations The registered person should re-evaluate the roles and responsibilities of the senior staff within the home. The registered person should review the current care plan format in place. Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 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 Broadwater Lodge DS0000033332.V265255.R01.S.doc Version 5.0 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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