Inspection on 02/07/07 for Broadwater Lodge

This inspection was carried out on 2nd July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broadwater Lodge 26/11/07

Broadwater Lodge 09/08/06

Broadwater Lodge 23/08/05

Broadwater Lodge 08/04/05

Broadwater Lodge 16/08/04

Broadwater Lodge 20/05/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Broadwater Lodge Broadwater Lodge Summers Road Farncombe Surrey GU7 3BF Lead Inspector Pauline Long Unannounced Inspection 2nd July 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broadwater Lodge DS0000013892.V342272.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 DS0000013892.V342272.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadwater Lodge Address Broadwater Lodge Summers Road Farncombe Surrey GU7 3BF 01483 414186 01483 422232 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) manager.burroughs@careuk.com Care UK Community Partnerships Limited Mrs Susan Jane Cripps Care Home 67 Category(ies) of Dementia - over 65 years of age (61), Old age, registration, with number not falling within any other category (6), of places Physical disability over 65 years of age (4), Sensory Impairment over 65 years of age (3) Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 5 (five) persons may be aged 50-65 years in the categories PD or DE Up to 10 persons may be admitted to the home for short stays only Date of last inspection 9th August 2006 Brief Description of the Service: Broadwater Lodge caters for the needs of older people, providing permanent and respite care, including specialist dementia care and a day care service. The home is situated in Farncombe a short distance from the local shops. Community facilities are nearby and easily accessible to the home. Residential accommodation comprises of 5 self-contained units. All bedrooms are of single occupancy, and the seventeen newly built rooms have en-suite toilet facilities. Each unit has its own bathrooms, toilets, lounge, dining area and kitchenette. The gardens are nicely arranged and safe for the residents to enjoy. Broadwater Lodge has spacious communal areas and the residents are encouraged to use and enjoy the whole building. The home has a shop run by volunteers, to enable residents to purchase toiletries, drinks, books and a number of other items on sale. There is ample parking in the front of the building. The fees at this service range from £390.00 per week to £800.00 per week. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.00 and was in the service for 6.5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. Following the site visit Care UK provided the Commission with information in respect of concerns about the registered manager. The Commission would like to thank the organisation for their vigilance in this respect and for their prompt response to the concerns raised. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Feedback from some of the residents was limited due to their communication difficulties. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The CSCI would like to thank the residents, the home manager, staff and visitors for their hospitality, assistance and co-operation during the site visit. What the service does well: The organisation is committed to ensuring that residents are not put at risk and when deficits are identified in this respect they respond in an appropriate and timely fashion. The manager and staff demonstrated an open and inclusive approach to the residents care. The resident’s benefit from a long standing staff team, some of whom have worked in the home for several years, and this was reflected in the level of knowledge and understanding of the needs and preferences of the residents. The home promotes and encourages contact with family/friends and the local community. Residents spoken with were complimentary about the care and services provided by the home. They commented that, they always get the care and help they need, “that the care they received was good” and “that the staff are very good”. Relatives commented that the staff at the home were professional, that they remained friendly and approachable and nothing was too much trouble. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 6 The standard of accommodation is good and provides the residents with a homely and pleasant place to live. One resident commented it is just like home. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What has improved since the last inspection? What they could do better: Care needs assessments are being completed, however at times staff signatures and dates are omitted. It was not clear as to when they were carried out or who had completed them. Following the site visit on the 2nd of July, information was received at the CSCI office on 16/07/07 in respect of 15 incidents not being reported under Regulation 37 of the Care Standards Act 2000. All of the incidents had a considerable impact on the health, safety and well-being of some of the residents and should have been referred to the local authority social care team, for consideration under the Safeguarding Adults Procedures. In order to ensure that all of the residents are protected from abuse, staff at the home must be aware of the procedures in respect of referring any potential safeguarding issues to the relevant authorities. It should be noted that Care UK brought this information to the Commission’s attention. There was evidence to indicate that safeguarding adults training is routinely undertaken at the home. However a member of staff recruited in January 2007 has yet to undertake this training. To ensure the continued protection of Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 7 the residents all staff must have a good understanding of, and undertake training in the home’s policies and procedures in this respect. Whilst staff group supervisions take place, there are major shortfalls in the process for formal one to one staff supervision meetings. In order to ensure the continued protection of the residents, improvements must be made, to ensure all staff have the appropriate support in order to do their jobs. All staff must have the required number of formal one to one supervision meetings with a manager or an appropriately trained senior member of staff. All meetings must be documented and clear and accurate records must be kept. The organisation has implemented a new IT system within the home in order to monitor the records in respect of the care service at the home. It is questionable as to how effective this system is in identifying issues in the home in light of the information received at the Commission. The system should be reviewed in order to assess its effectiveness in identifying concerns with the reporting and recording systems at the home. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. 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 DS0000013892.V342272.R01.S.doc Version 5.2 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 DS0000013892.V342272.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents are only admitted to the home following an assessment of their needs. The home does not provide an intermediate care service. Improvements could be made in the needs assessment documentation in respect of staff signatures. EVIDENCE: The home provides a service for both Local Authority and Privately funded residents. The manager stated that following a referral from either a Local Authority care management team or a privately funded service user, the prospective resident would be visited at their home or hospital or invited to the home for a days/overnight assessment period. The home would expect to receive a care management care needs assessment for Local Authority service users. This was evidenced in residents’ files. The manager stated that the pre-admission assessment would then be carried out, by a competent member of senior staff. If any concerns were raised then a Health Needs Assessment would be requested, before a decision was made as to whether the home could meet the prospective residents needs. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 10 Three of the most recently admitted residents care needs assessments were sampled and were being completed in conjunction with a Care Management Care Needs assessments. The home’s care needs assessments format covered all daily living activities, however some of the areas had not been fully completed, this could be due to the fact that there were no identified needs in these areas. However this needs to be made clear in the document. These areas were discussed with the manager, and she explained that the assessments had been carried out at the weekend and had not been fully completed, but the staff were consulting the care management care needs assessments in order to ensure that all care needs were being addressed. It was noted that the care needs assessments had not been signed by the member of staff completing them. This was addressed straightaway as the member of staff was on duty. The home does not provide an intermediate care service. A recommendation has been made in respect of these standards. Please refer to pages 27 and 28 of this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Changes in resident’s health care needs are not being appropriately identified, and referred to the relevant health and social care professionals in order for these needs to be met. Residents are treated with respect and their privacy and dignity are promoted. EVIDENCE: The system at the home for developing and recording residents care plans has changed. All of the documentation is now recorded and stored electronically. Each of the units and all of the offices are connected to the home’s IT system and all of the staff have been trained to complete the care plans and daily records in this way. Four of the residents care plans were sampled and were found to be satisfactory. They included information on all daily living activities, and likes and dislikes. The information recorded gave the reader a reasonable view of a residents needs, identified risks, their health care needs and goals. All of the plans sampled had been regularly evaluated and updated according to ongoing needs. The manager commented that more improvements could be made in the quality of information provided and that staff had undertaken training in reporting and recording. This was evidenced Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 12 in the home’s training records. Discussions were had with the manager in respect of the involvement of relatives in developing the care plans and the accessibility of care plans for residents and their families. She stated that relatives are encouraged to become involved in developing the plan and that they can access the information on screen on any of the units, and if required hard copies could be printed off for them to read. She also commented that confidentiality of information was a priority and only those who are authorised can access the documents. Discussions were had with one relative in respect of the care planning process at the home. She commented that she and her mother had been involved in the process and were happy with it. Discussions were also had with the care staff in respect of the new system. They commented that it was good. Some of the care staff are only permitted to access and add to the daily records, others can access and change the care plans and risk assessments as required. Following information from Care UK received at the Commission on the 16/07/07 it was evident that residents changing health care needs were not being identified and referred to the appropriate professionals in a timely manner. It has been noted that the Organisation’s Clinical Governance Team regularly audit the care plans and other records in respect of incidents and accidents. There is a considerable question as to the effectiveness of this system in view of the incidents that were recorded on the system and were not picked up as potential safeguarding issues. The commission has received several notifications in respect of residents falling at the home. These were discussed with the manager. She stated that the organisation had implemented a Falls Strategy Management process, for example: those residents at risk of falls are provided with protective aids and residents are referred to the Falls Clinic, it was noted that one resident had gone to the clinic on the day. As mentioned in the previous paragraph, the Clinical Governance Team monitor the home’s records on a regular basis via the IT system in order to identify any falls and to offer guidance and advice to the home. The home’s policies and procedures in respect of administration, record keeping and storage of medication were sampled. Medication administration was observed and was found to be carried out in a sensitive and safe manner. The storage of general medication was found to be safe as was the storage of controlled medication. Medication record sheets and the controlled drugs register were sampled, and were found to be well documented with no gaps in signatures noted. Discussions were had with the care staff about the home’s medication policies and procedures. It was evident through these discussions, that the staff had a reasonable understanding of the policies and procedures. However the home has a medication audit in place where medication records sheets are checked for omissions in signatures. This audit was discussed with staff and there was Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 13 some confusion in respect of what happens when a gap in signature is identified. The care staff were advised to discuss the system with the manager. The inspector raised this issue with the manager at the time. The manager discussed the medication training at the home. She stated that only staff who had undertaken medication training and who were deemed competent were permitted to administer medications. Care staff confirmed this. Training records evidenced that medication training had been undertaken in this respect. It was noted that a short one hour course in medication administration was undertaken by some of the care staff during the site visit. The manager should satisfy her self that care staff would be competent to administer medication following such a short course. Throughout the inspection process, staff were observed carrying out various aspects of personal care for the residents, this support was offered in a respectful and sensitive manner. Staff were observed knocking on doors and waiting to be invited in, before entering rooms. Bathroom doors were kept closed whilst staff were attending to residents personal care needs. Residents and relatives commented that, all of the staff were kind and treated them with respect. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use the service experience good quality outcomes in this area. The residents are encouraged and enabled to maintain fulfilling lifestyles and contact with family friends and the local community is encouraged and promoted. Residents are encouraged and enabled to makes choices in their lives and meal times at the home are a positive and pleasant experience for the residents. EVIDENCE: The manager stated that the home is committed to ensuring that the residents maintain their relationships with their family and friends. They are also encouraged to maintain contact with their families via telephone. Residents commented that they received visits from their families and friends. Some relatives and visitors were observed visiting the home during the site visit. There was evidence of various flyers and photographs on the home’s notice boards relating to activities. Many of the photographs evidenced smiling faces, indicating enjoyment. The manager commented, that all residents are encouraged to take part in all activities, and social events, not all wish to take part. One relative commented that, perhaps more activities could be offered, that at times many of the residents are left to sleep. This was discussed with the manager at the time. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 15 Residents spoken with were happy with the activities provided in the home. One commented that it would be nice to see more of the local school children visit the home again. During the visit fourteen residents were observed taking part in an exercise class, this generated much noise and considerable laughter, and all appeared to be enjoying the class. Other residents were observed to be walking freely around the home chatting and smiling at each other. Several residents were asleep in their armchairs and one resident was resting in bed. The home actively encourages all of the residents to practice their faith and staff are aware of the importance of spiritual support. Residents are encouraged to attend the monthly Church service held at the home, or if they wish to go to the local church the home would provide support in this respect. Residents were observed moving freely around the home, making choices as to how they would spend their day. Staff were observed offering choices in respect of meals, drinks and activities. The meals at the home are provided by an outside catering company and are prepared as Cook/Chill. The four-week menu was sampled and was seen to be well balanced, wholesome and allowed for seasonal changes. Two main courses and a vegetarian option are offered each day. One relative commented, that since the catering had been outsourced, choices were limited. This was discussed with the manager at the time, who, stated that the home is working closely with the caterers in order to ensure the meals supplied reflect the residents choices. Discussions were had with the Chef in respect of resident’s likes and dislikes. She demonstrated a good understanding of each resident’s likes and dislikes, and specialist diets, for example diabetic, vegetarian and soft diets. Residents and relatives commented that the food at the home was good. The lunch time activity was observed on two of the home’s units. Residents were given choices as to what they would like to eat. On the whole the food was nicely presented, however the presentation of soft diets could be improved and this was discussed with the manager at the time. Some residents required support with their meals, this support was offered in a sensitive, dignified and unhurried manner. A recommendation has been made in respect of these standards. Please refer to pages 27 and 28 of this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 16 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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents are not protected by the home’s policies, procedures and practices around concerns, complaints and protection. Improvements are required in respect of safeguarding adult referrals and staff training in the home’s safeguarding adults policies and procedures. EVIDENCE: No complainants have contacted the Commission with information concerning a complaint made to the service since the last inspection. The home has received four complaints in the last twelve months. Evidence seen indicates that have been investigated under the home’s complaints procedures and have been satisfactorily resolved. Residents and relatives commented, that they were aware of the complaints procedure, and if they had any reason to complain, they would speak with the manager. The home’s complaints procedure is provided in each of the resident’s bedrooms and various prominent positions throughout the home. Complaints forms are now easily accessible to everyone in the home. Six referrals have been made under the local authority multi agency Safeguarding Adults procedures. Meetings have been held in this respect of 4 of these referrals. The issues have been investigated and satisfactorily resolved. Following the site visit in July, information was received at the CSCI office from Care UK in respect of 15 incidents not being reported under regulation 37 of the Care Homes Regulations 2000. All of the incidents involved one of the Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 17 residents at the home and had a considerable impact on the health, safety and well-being of some of the other residents. None of the incidents had been referred to the local authority social care team, for consideration under the Safeguarding Adults Procedures. Discussions were had with the staff on duty and scenarios put to them in respect of the home’s safeguarding adults and complaints procedures. On the whole, staff interviewed demonstrated a good understanding of the policies and procedures. However the inspector advised that they should discuss the procedures with the manager to ensure clarity. This was discussed with the manager at the time. She stated that she would review the training programme in this respect. The majority of the staff group have undertaken safeguarding adults training as evidenced in the training records. However one member of staff employed since January 2007 has yet to undertake this training. The manager stated that places on the Local Authority Multi Agency Training courses were limited and that she was looking for an alternative training course provider. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 18 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, 24, 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is able to meet the changing needs of the resident’s, it is homely, clean, safe and comfortable. EVIDENCE: The home is a purpose built property and has been extended to provide a further seventeen bedrooms with en-suite facilities, two smaller lounges/quiet rooms and conservatories, where residents and families can spend time if they wish. The manager discussed the plans for refurbishing and the purchase of further furnishings. It was noted that there was a leak in the conservatory roof and that the light in one of the communal lavatories was out of order. This was discussed with the manager at the time, and these issues had been recorded in the maintenance log to be addressed. Resident’s bedrooms had been nicely personalised with photographs, pictures, small items of furniture and ornaments. The majority of the bedrooms benefit from specialist profiling beds, which provide those frailer residents with beds Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 19 more suitable for their changing needs, and provide staff with a safer working environment. On the whole the home was clean and hygienic. Staff were observed to use protective clothing and gloves in order to minimise the risk of cross infection. The majority of the home was freshly aired, which, given the high continence needs of many of the residents is commendable. It was noted however that one of the unit’s sitting rooms required improved odour control. The manager commented that the staff at the home were working hard to minimise any malodour. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements are required to ensure all staff understand the home’s Safeguarding Adults procedures and are aware of the requirement to refer all incidents which affect the health, safety, and well-being of the residents to the appropriate authorities. EVIDENCE: Staff files sampled, and work based observations evidenced that the home employs a diverse staff group. The home benefits from a stable staff group and on the day the staffing levels were adequate for the dependency levels of the residents. The staffing rotas evidenced that there were eleven care workers and an activities co-ordinator on a morning shift, ten care workers on an afternoon shift and five care workers and one team leader on a night shift. The home has recently increased the hours allocated to activities and employed a further activities assistant, which, provides for more time for social interaction on the units. A new deputy manager has been appointed and the manager was hopeful that this person would be joining the team quite soon. The manager stated that there is no agency usage at the home. Care staff commented, that, at times the team leaders do not have the time to carry out work based observations and are not always aware of what is going on in the units. This was discussed with the manager at the time. She was confident that the team leaders would spend time on the units and would be aware of what was going on in the home. Residents and relatives commented Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 21 that all of the staff were kind, helpful, knew what they were doing and good at their jobs and were professional. The home’s recruitment practices were sampled, and were found to be good. Three staff files were sampled and all had the required documentation in place, with evidence of CRB (Criminal Records Bureau) or POVA (Protection of Vulnerable Adults) checks. There was evidence of the staff interview process on each of the sampled files, indicating that the recruitment process was based on equal opportunities. Discussions were had with staff, who, talked about their job roles and responsibilities. Work based observations evidenced confident staff carrying out their various tasks. Training is given a high priority at the home, and staff discussed some of the recent training they had undertaken in respect of the L Box system. In order to undertake this training the staff are required to have access to the home’s laptop computer. Staff commented that it was difficult to undertake this training as there was only one laptop supplied between 60 staff. Training records demonstrated that statutory and various current good practice training had been undertaken since the last inspection for example: dementia care, manual handling, health and safety, adult protection, reporting and recording. The manager stated that some of staff have undertaken English language courses at a local college and further classes have been provided at the home. The home is proactive in promoting NVQ (National Vocation Qualifications), and the manager stated that they had achieved 47 of the National Minimum Standard recommendation of having at least 50 of care staff with NVQ2 or above. As mentioned earlier in this report one member of staff has yet to undertake training in safeguarding adults. The manager commented that training courses were arranged to ensure that all staff have an opportunity to attend, for example; training courses timed in the evenings and at night time to enable the night staff and staff with carer responsibilities to attend. As discussed earlier in this report there are concerns in respect of staff not reporting incidents and accidents to the appropriate authorities. In order to ensure the continued health, safety and protection of the residents, the staff training in respect of reporting and recording must be reviewed, and all staff must undertake training in this respect. Requirements and a recommendation have been made in respect of these Standards. Please refer to pages 27 and 28 of this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 22 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, 36,37,38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management arrangements at the home do not promote and protect the health, safety and welfare of the residents. EVIDENCE: As discussed earlier in this report, there are serious concerns in respect of the home’ s failure to report several incidents under Regulation 37 of the Care Standards Act 2000, and failed to refer these incidents to the Local Authority for consideration under the Safeguarding Adults Procedures. It should be noted, however, that Care UK promptly brought these matters to the attention of the Commission when concerns were raised. As discussed earlier in this report, it has been noted, that, the Organisation’s Clinical Governance Team regularly audit the care plans and other records in respect of incidents and accidents. There is a considerable question as to the Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 23 effectiveness of this system in view of the incidents that were recorded on the system and were not picked up by the Clinical Governance Team as potential safeguarding issues. The manager is a registered nurse with twenty years experience caring for older people. She is undertaking the Registered Managers award, has one module to complete and hopes to complete this in the near future. She stated that she attends relevant training to enhance her skills and knowledge. It was observed that she knew all of the residents by name and that the residents responded well to her questions, were confident and relaxed in her company. The manager stated that the home actively seeks the views of the residents. Residents meeting are held, where residents and their relatives are encouraged to express their views. These meetings are chaired by a representative from the Alzheimer’s Disease Society. One relative commented that the meetings were very good, and that she enjoyed coming to them. The organisation undertakes a yearly audit of service users views and this forms part of the overall Quality Audit. The home also sends out service user questionnaires to residents and their relatives. Some were sampled and were found to be complimentary of the care service provided at the home. The home has recently developed a service user survey in respect of “Faith and Dementia”. This has been sent out to relatives/friends in order to gain further information with regards to a resident’s belief, and whether or not they would wish to practice their faith. Discussions were had with the manager and administrator in respect of the resident’s personal finances. The home holds small amounts of monies in resident’s personal accounts in order to meet the day-to-day needs for toiletries, reading materials and other consumables. The records in respect of these personal accounts were sampled and were found to be accurate and well documented. Discussions with the manager and care staff evidenced that one to one staff supervision meetings are not being held. Care staff commented that if they wished to have a discussion with a manager, she operates an “open door” policy. The manager stated that due to workload, there were challenges in respect of carrying out the required formal one to one supervision meetings. She was confident however that this area would be addressed when the new deputy manger was in post. Staff are expected to attend quarterly staff meetings, the most recent one having been held on the 30th June. Care staff confirmed this. The minutes of the meeting were not sampled during the site visit. There was evidence to indicate that all of the home’s policies and procedures were reviewed in March 2007. There are however concerns in respect of record keeping, reporting and recording as discussed earlier in this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 24 Health and safety audits are routinely carried out at the home. Risk assessments are completed and reviewed in respect of risks to residents and staff. A member of staff fully qualified in first aid is on duty twenty-four hours a day. Records evidenced that water temperatures, fire drills and fire bells and other safety equipment had been regularly checked. All of the equipment in the home had been properly maintained and serviced. The home had a visit from an Environment Health Officer in January 2007. The requirements and recommendations made at that time have been addressed and met. Requirements have been made in respect of these standards. Please refer to pages 27 and 28 of this report. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 1 1 1 Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP10 Regulation 12(1)(a) Requirement Changes in resident’s health care needs must be appropriately identified and referred to the relevant health and social care professionals in order for these needs to be met. To ensure the continued protection of the residents, all staff at the home must undertake training in respect of the home’s Safeguarding Adults Procedures. A formal staff supervision process must be implemented. (a) To ensure that all staff have the required number of one to one supervision meetings with a manager or an appropriately trained senior member of staff. (b) These meetings must be documented and clear and accurate records kept. All staff must ensure that incidents and accidents which affect the well-being of a resident are reported under Regulation 37 of The Care Homes Regulations to the CSCI and other appropriate DS0000013892.V342272.R01.S.doc Timescale for action 16/08/07 2. OP18 12(1)(a) 13(6) 02/09/07 3 OP36 18(2)(a) 02/08/07 4. OP18 12(1)(a) 16/08/07 Broadwater Lodge Version 5.2 Page 27 5. OP30 18(1)(a) (c ) 6. OP31 9 12(1)(a(b 13(6) 12(1)(a) 13(6) 17 24 7. OP33 OP37 OP18 authorities. All staff must undertake training in respect of recording and reporting incidents, which affect the health, safety, and well-being of a resident. The management arrangements in the home must be reviewed to ensure the continued protection of the service users. The systems in place for Clinical Governance auditing and monitoring of records in respect of care practice must be reviewed and amended in order to ensure they are effective, and that they identify and deal with areas of concern in a timely fashion. 16/09/07 16/08/07 16/08/07 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. 2. 3 Refer to Standard OP3 OP15 OP30 Good Practice Recommendations The manager could consider how best to ensure that staff sign and date all care needs assessments. The manager could review the presentation and serving of soft diets/pureed food to in order that she could be confident that these meals look appetizing and appealing. The organisation could consider the difficulties the staff encounter with the L Box training and consider supplying further equipment. This would help to ensure all staff could undertake this training in a timely fashion. Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Broadwater Lodge DS0000013892.V342272.R01.S.doc Version 5.2 Page 29 - 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. 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