Inspection on 19/04/07 for Broadwater Lodge

This inspection was carried out on 19th April 2007.

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 25/05/06

Broadwater Lodge 12/01/06

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 Caroline Mitchell Key Unannounced Inspection 09:45 19 & 25th April 2007 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.V333340.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 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), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (45), Old age, not falling within any other category (45) Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 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. Placements at the home costs around £525 for each person per week. Residents are expected to pay separately for some toiletries. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to Residents and other stakeholders. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed over one day and a half days. The registered manager assisted the inspector throughout the inspection. The inspection involved sampling a number of care plans, various other records, a tour of the building and observing the interaction between staff and Residents. The inspector spoke to several staff and residents during the inspection. The registered manager and the staff that the inspector met were very open and helpful throughout the inspection. Prior to this inspection the inspector received a copy of the home’s PreInspection report. Feedback was generally very positive. A complaint made by a relative of 1 person living in the home was being investigated by the registered persons at the time of the inspection and a number of requirements and recommendations are made that are relevant to the issues raised. The overall impression was that the registered manager and staff team have a good overall knowledge and experience and are committed to promoting the wellbeing of each person living in the home. The team, and particularly the registered manager were open to suggestion and advice. The inspector would like to thank the people living in the home, the registered manager and the staff team for their time, patience and co-operation during the inspection process. There were 36 people living in the home at the time of the inspection. What the service does well: What has improved since the last inspection? There were 19 areas for improvement identified at the last inspection and the majority of these have been addressed. These included addressing issues about the registration of the home, improving monthly review summaries in Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 6 terms of risk and goals and health and mental health concerns for residents, managing the risk of falls, ensuring that CRB checks are in place for agency workers, updating policies and practice regarding disguising medication and reviewing the role of the senior team. There were also a number of requirements linked to completing the refurbishment of the building, the use and disposal of equipment in the kitchen, and some health and safety checks. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose, which sets out the aims and objectives of the home, and includes a service user guide, which provides basic information about the service and the specialist care the home offers. However, the service user guide has not always been provided to people moving into the home, and when this has happened, it has left their representatives unclear about what the service offers. EVIDENCE: Although a service user guide is in place, which sets out the details of the home, at the time of this inspection the registered persons were dealing with a complaint from one persons relatives, and part of this was that they were not provided with a guide to what they could expect from the home at the time of the admission. It was apparent that the circumstances of this particular admission did not follow that which was usually expected by the staff in the home, and that this may have caused some procedures to be missed or Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 9 disrupted. A requirement is made in relation to providing a service user guide to the person being admitted and to their representatives. At the last inspection the registered persons were required to amend the homes Statement of Purpose to include a section on the qualification of the registered provider. The inspector noted that the registered manager has provided an updated copy of the statement of purpose to the Commission. At the last inspection the registered persons were required to submit an application to the CSCI regarding a major variation to accommodate the residents who at present reside in the home with a mental health disorder. At this inspection the inspector found that this issue had been addressed and the certificate of registration reflecting that the home is able to admit people with mental health problems, was displayed appropriately. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use services have access to health care services both within the home and in the local community. People who use services are able to have access to community health services. People who use services unable to access local services are managed by visits to the home by health care professionals. The home understands the need to comply with the administration, safekeeping and disposal of medication. Medication systems do not always follow good practice or safe practice guidelines and has needed action, the registered person has responded. Although staff generally think in a person centred way when considering an individual’s personal care needs, there is room for improvement in protecting peoples’ privacy. EVIDENCE: At this inspection the inspector observed that a district nurse was visiting the people who required nursing monitoring and treatment, and had changed a dressing for one person in the presence of other people living in the home. The registered manager explained that this is not the usual practice, but that Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 11 this resident can sometimes become distressed and reluctant to accompany the nurse to their bedroom. A recommendation is made in relation to this. The inspector noted that the home being organised in small units does help to maintain peoples’ privacy and dignity. However, it was part of the complaint being addressed at the time of the inspection that some residents are able to enter other residents’ bedrooms, and have taken items of clothing. It is recommended that the registered persons review how to better protect the privacy and security of residents’ bedrooms. At the last inspection the registered persons were required to ensure that a number of improvements were made to the care plans and risk assessments for the people who live in the home, particular in relation to the risk of falls, and other health care needs, such as diabetes. This was in order to ensure that risk assessments and care plans kept pace with people’s changing needs. At this inspection the inspector reviewed the plans and risk assessments for 4 people who live in the home. One person had diabetes, another had fallen recently, one had a pressure sore and another had a leg ulcer. In each case the care plans and risk assessments had been updated to reflect the changes, needs and risks for each person. The monthly summaries had been kept up to date and notes were kept of the input from the relevant health professionals involved in people’s care, such as GPs, Psychogeriatricians, District Nurses, and Dieticians. The interventions and treatments that were in place were recorded and, any equipment, such as ripple mattresses, was included. The home was not using bedrails for anyone at the time of this inspection. In addition to their diabetes 1 person told the inspector that they had had been diagnosed as having food allergies. This was clearly noted in their records, along with appropriate interventions and treatment. The staff who the inspector spoke to were aware of this person’s needs. It was also previously recommended that the monthly weight records kept for residents were recorded in either stones or kilograms to ensure that if individual’s weights fluctuate this can easily be identified and the appropriate action taken. At this inspection all of the weight records seen by the inspector were recorded in kilograms. In the case of the people who were diagnosis as having a mental illness, the registered person was previously required to have in place a clear and comprehensive care plan that is specific to their mental health needs. The inspector reviewed the plan and risk assessment for 1 person who has mental health needs such as hoarding, and the records included how the home supports the individual and how this is monitored and reviewed. The registered persons were required to ensure that a thorough risk assessment is completed for each resident who is supported by the activity person on any external outing. However, at the time of this inspection, there Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 12 was no activity co-ordinator in post. The registered manager explained that the recruitment process is being followed and a new activity co-ordinator will take up the post in the near future. In the light of this the inspector did not review this requirement. However, it remains relevant, and it is planned that it will be reviewed at the next inspection. At the time of this inspection the registered person was dealing with a complaint from 1 person’s relatives regarding errors made in the medication administered to the resident. Due to the nature of the admission of the resident, a number of mistakes were made in recording the medication that was to be administered, which led to the wrong medication being given to the resident for a number of weeks. This issue was being dealt with through the local authority’s adult protection procedure. A requirement is made as part of this report, in order to ensure that the policy and practice around dealing with medication, as part of the admission process, is made more robust. There is a medication policy in place, and during this inspection the inspector found no evidence to raise further concerns regarding the competence of the staff administering medication. There were a limited number of senior staff involved in the administration of medication and they had received appropriate training. However, in the light of the nature of the complaint, a recommendation is made in relation to further, specialist training. At the last inspection the registered persons were required to ensure that update the medicines policy and include a section dealing with the possibility of disguising the medication, if non-administration will seriously endanger a resident’s health. At this inspection the inspector reviewed the medication policy and found that this had been addressed. The registered manager told the inspector that the home had the permission from the GP for 1 person living in the home, to disguise their medication. The inspector reviewed the records of this person and found that written permission from the GP was included. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Generally staff are aware of the need to support residents to develop their skills, including social, emotional, communication, and independent living skills. Some residents are consulted or listened to regarding the choice of daily activity, but this process could be improved. People using the service need to be given more opportunity to take part in a variety of activities both within the home and in the community. The food in the home is of satisfactory quality, well presented and meets the dietary needs of people who use the service. EVIDENCE: Several of the people living in the home told the inspector that church services are provided in the home for people who are Church of England, on a regular basis, and that for the Catholic residents, transport is provided to a local church. At the time of this inspection the registered person was dealing with a complaint from 1 person’s relatives that the resident’s social and recreational needs were not being taken into consideration or met. The inspector found that there was no activity co-ordinator in post and that this had certainly had a negative impact on the quality of care provided in this area of people’s lives. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 14 The inspector noted that there is an area, in one part of the home that is well equipped for activities, and that this is a good resource. However, it is being under used, and during this inspection the majority of residents tended to be sitting and watching television in each of their units. The registered manager explained that a candidate for the post is awaiting a start date, subject to preemployment checks, and that in the meantime she is considering employing an agency worker to cover the post. A requirement and a recommendation are made in relation to these issues. At the last inspection the registered persons were required to address issues around the records kept of all meal prepared in the home and food storage. At this inspection the inspector found that these issues had been addressed. It was also previously recommended that the registered person consider purchasing food items in smaller portion sizes, rather than in bulk and the registered manager explained to the inspector that smaller sizes in foods such as cereal were now being purchased. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. EVIDENCE: There is a clear complaints procedure in place, and the record of complaints received and recorded was up to date and included detailed information about any actions taken. As previously stated the home was dealing with a complaint regarding 1 resident at the time of the inspection. This complaint featured issues such as the wrong medication being recorded and administered, unexplained bruising, lack of space, lack of activities and lack of security in the person’s room. The local authority invoked an investigation under their adult protection procedures to deal with some aspects of the complaint. The issues raised in this complaint are referred to throughout this report. The inspector noted that the registered manager responded appropriately, and was open to finding ways of address the issues raised in a positive manner. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 16 Records reflect that staff have received training regarding the protection of vulnerable adults from abuse and the 5 staff that the inspector spoke to in depth demonstrated that they were clear about their responsibilities in terms adult protection. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 25 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet the needs of the people who use the service. The home is a pleasant, safe place to live the bedrooms and communal rooms meet the NMS. The lay out and design of the home allows for small clusters of people to live together in a non-institutional environment. The home is well lit, clean and tidy and smells fresh. EVIDENCE: The inspector toured the building and found that the home is divided into smaller units, 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 residents from an Afro Caribbean background. All units have been decorated to a high standard and are well maintained, which provides aids and equipment to meet the care Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 18 needs of the residents. Each resident’s bedrooms are decorated also to a high standard and generally reflected individual style and taste. The premise is kept clean, hygienic and free from offensive odour. All staff are aware of the policies and procedures relating to ‘Control of Infection’ this was observed by the inspector on the day. The laundry room was found to be good order. Clinical waste is properly managed and stored. There was some flaking paint in 2 of the pantries, and this was addressed at the time of the inspection. The inspector found that 2 of the units are quite restricted in terms of the communal space available, and this was a feature of the complaint that was being investigated at the time of the inspection. It is the opinion of the inspector that the lack of an activities co-ordinator contributed to this, as some residents were not getting opportunities to get out for day activities, resulting in them being in their units most of the day. Requirements are made in relation to the employment of an activities co-ordinator in this report, in order to address this issue. There was some disruption at the time of the inspection as there were a number of contractors coming in and out of the home. CCTV was being installed to monitor the outside of the building and contractors were trying to rectify an issue with the fire alarm system, that was resulting in the fault buzzer being activated at regular intervals. At the last inspection the registered persons were required to ensure that a number of issues regarding the use and disposal of kitchen equipment were addressed. Additionally, throughout the rest of the building, the registered persons were required to ensure that the call point instruction are clear completed, that the windows on the top floor have appropriate window restriction in place in, that the portable phone in Rowan unit is replace or repaired and that the health and safety notices be completed. At this inspection the inspector found that these issues had been addressed. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using services are generally satisfied that the care they receive to meet their needs, but there are times when they may need to wait for staff support and attention. The service has a recruitment procedure that meets the regulations and the National Minimum Standards. The procedure is followed in practice and there is accurate recording at all stages of the process. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. EVIDENCE: The inspector reviewed the written records of 6 staff working in the home and spoke to 5 staff in some detail. It was evident that staff have access to a good range of training, including the necessary core training and other specialist training that is relevant to the needs of the people living in the home. The registered persons also ensure that all staff employed, including agency workers, have proper pre-employment checks and an Enhanced Criminal Record Bureau (CRB) check in place before commencing work in the home. It was evident that the care staff that had recently started employment were supported appropriately as evidence indicated that supervisions and induction programmes were in place. It was also evident that over 50 of the care staff have completed their NVQ level 2 and above. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 20 This is a large team and includes management and care staff, ancillary staff such as cooks and domestics, and laundry assistants. The ethnic make-up of the staff team is very varied, matching the resident group being supported. At the last inspection the registered persons were required to ensure that supervision is undertaken at least six times a year with the activity person and records of this must be kept on file, and to ensure that the activity worker undertakes training in dementia care based on appropriate activities for residents with dementia care needs. As previously mentioned there was no activity co-ordinator in post at the time of this inspection, and the registered manager was addressing this issue. As these requirements remain relevant, and were not reviewed at this visit, it is planned to review them at the next inspection. It was previously recommended that the registered persons should re-evaluate the roles and responsibilities of the senior staff within the home. The registered manager has addressed this with the introduction of further opportunities for staff to develop and to take on further responsibility. However, it also became evident both in talking to the care staff, and observing practice in the home, that there are key times during the day when there is 1 member of staff on duty in the units and this can place staff under quite a lot of pressure in meeting people’s care needs. It is recommended that a review of the deployment of staff at key times, in order to ensure that sufficient staff are available to meet the needs of residents at all times. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered manager has the required qualification/s and experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for residents with a strong focus on equality and diversity. There is an ethos of being open and transparent in all areas of running of the home. The registered manager’s practice, skills, and knowledge, is based on continuous development, gained through training and enthusiasm for the role. The home works to a clear health and safety policy, all staff are fully aware of the policy and are trained to put theory into practice. Regular random checks take place to ensure they are working to it. Safeguarding is given priority and the home provides a range of policies and guidance to underpin good practice. EVIDENCE: Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 22 The registered manager holds the an NVQ level 4 in Management and Care certificate and comes across as very committed to improvement, open and frank. There are clear lines of accountability both within the home and with external management. Discussion with staff suggested that they see the registered manager as open and approachable. During the tour of the building, interaction with residents was warm, with the registered manager showing detail of knowledge about each person. Records examined indicated that staff meetings are held regularly. There are regular residents meetings. It was evident that the commitment is made to ensure equal opportunities and meeting individual’s diverse needs is a part of the ethos of the home. There is an effective quality assurance and quality monitoring system, based on seeking the views of residents. The majority of residents either control their own money or have their financial affairs managed by their families. The new administrator spoke to the inspector at the time of this inspection, and reported that there were good safeguards in place to protect residents from financial abuse. Health and Safety certificates were examined. Portable Appliance Testing (PAT), lift service, fire extinguishers, fire drills and checks, water temperature checks, hoist & bath chair and emergency lighting checks were all in place. An environmental risk assessment, which includes a fire risk assessment, was in place. At the last inspection the registered persons were required to ensure that the water supply (water Fittings) Regulation 1999 were met with regards to Legionella, gas and electrical installation certificate. This had been addressed. Core training around moving and handling, food hygiene, fire safety first aid and infection control is updated by the organisation to ensure staff are clear about their responsibilities around heath and safety in the home. Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X X X X 3 X STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 24 YES 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 OP1 Regulation 4 Requirement The registered persons must ensure that people moving into the home, and their representatives are provided with a service user guide. The registered persons must ensure that a thorough risk assessment is completed for each resident who is supported by the activity person on any external outing. This requirement was not reviewed at this inspection. The registered persons must revise the policy regarding medication to ensure that it is more robust in the area of accepting, recording medication whilst admitting a resident to the home. This must include contacting the person’s GP to confirm the details of prescribed medication within 2 working days of admission. The registered person must ensure that all staff dealing with medication be made aware of Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 25 Timescale for action 30/06/07 2. OP7 15 30/07/07 3. OP9 13 30/07/07 the revised procedure. 4. OP12 18 The registered persons must 30/07/07 ensure that the vacancy for the activity co-ordinator be addressed, in order to ensure that the people who live in the home are provided with activities appropriate to their needs. The registered person must ensure that the activity worker undertakes training in dementia care based on appropriate activities for residents with dementia care needs. This requirement was not reviewed at this inspection. The registered person ensure that 1-1 supervision is undertaken, at least 6 times per year, with the activity person and records of this must be kept on file. This requirement was not reviewed at this inspection. 30/07/07 5. OP30 18(1)(c)(i) 6. OP36 18(2) 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is recommended that all staff dealing with medication be provided with further training regarding the nature, special precautions, and possible side effects of the medication regularly prescribed to the people living in the home. It is recommended that the registered person review methods of protecting the privacy of one person, on the occasions that they become too distressed to accompany DS0000033332.V333340.R01.S.doc Version 5.2 Page 26 2. OP10 Broadwater Lodge the nurse to their room for treatment. 3. OP10 It is recommended that the registered persons review methods of better protecting the privacy and security of residents’ bedrooms. It is recommended that the care plans for each person be expanded in relation to their needs around social, leisure and recreation. It is recommended that the registered persons undertake a review of the deployment of staff at key times, in order to ensure that sufficient staff are available to meet the needs of residents at all times. 4. OP12 5. OP27 Broadwater Lodge DS0000033332.V333340.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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