Inspection on 25/05/06 for Broadwater Lodge

This inspection was carried out on 25th May 2006.

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

The inspector 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 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 Karen Malcolm Key Unannounced Inspection 25th May 2006 10.20 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.V291193.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 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.V291193.R01.S.doc Version 5.1 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 Minimum 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. 12th January 2006 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.V291193.R01.S.doc Version 5.1 Page 5 Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request at the reception desk. The current scales of charges are from: - £388.50 per week. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 6 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 eight hours. The registered manager assisted the inspector throughout the inspection. The staff present on duty were two assistant managers, seven carers, one cook, one assistant cook and four support workers that included the laundry person. A present the home supports Rowan unit has nine service users, Lower Ground has six, Ground Floor has five, Hibiscus unit has seven service users all from the same ethnic background who are for Afro Caribbean, and Holly unit has seven. Primrose unit is the intermediate unit at present this unit is housing seven service users from The Red House who are supported by their own staff team. The Red House at present is under-going a major refurbishment, which is allocated for completion in August 2006. However, the manager informed the inspector that until such time the Intermediate Unit is still under negotiation with funders. Further discussions on this matter are to take place regarding the unit future. The service users group within the home are culturally diverse and an experienced, skilled, culturally diverse care staff team matches this. At present the home has one vacancy. The inspection involved sampling a number of care plans, various records pertaining to the service of the home, a tour of the building and observing the interaction between staff and service users, was friendly and caring. The manager and all staff 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 and comment cards from service users and other professionals. Feedback recorded was generally very positive. The findings from the inspection was that the manager and staff team have a good overall knowledge and experience of the well being of each service users living in the home. The support and care mechanisms that are in place were also deemed good, however, there were some room for improvement with regards to monitoring and reviewing. The manager was open to suggestions and advice, which was seen positive by the inspector. The inspector would like to thank the manager, carers and service users for their time, patience and cooperation during the inspection process, which was positive and open. 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 Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 7 from an Afro Caribbean background. The team supporting service users compliments the users group and are skilled, dedicated and experienced. Service users spoke 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 ensured 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 menu plan offered by the home is a good choice of food. Individual preferences are catered for within this it includes meeting cultural and dietary needs. What has improved since the last inspection? What they could do better: This inspection has identified eighteen areas of improvement and three recommendations. While it’s evident that the staff are experienced and competent, the home has failed to ensure that service users needs are consistently being, reviewed, monitored and up-dated appropriately. It is therefore required that the registered person submits an action plan to the Commission for Social Care Inspection (CSCI), which describes how they will address these matters. The summary of findings is that the registered person is to ensure that an application is made to the CSCI with regards the home accommodating the service users who have a mental health disorder. The registered person is to cease the practice of admitting any service users with mental health problems into the home until such time as the application for variation has been Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 8 approved by CSCI. The Statement of Purpose is to be amended to reflect the qualification of the registered provider. Any changes in care needs such as falls, must be up-dated accordingly on the service user’s care plans along with risk assessments. The registered person is to seek advice and guidance from the relevant professional with regards to managing service users who are deemed high risk of falling. Those service users who are diagnosed with diabetes have in place on their care plan/s comprehensive risk assessment. Risk assessments are to be fully completed ensuring the correct risk level of risk is recorded on each service user care plan. Service users who are diagnosis with a mental health illness are to have in place a clear and comprehensive care plan that is specific to their mental health needs. The complaint regarding the specific service user and the action taken is to be clearly documented on their care plan. Monthly summaries are to address all the areas of risks and goals set for individuals’. All staff employed, such as agency workers, must have in place before commencing work in the home an Enhanced Criminal Record Bureau (CRB) check that has been completed by the agency. The activity worker is to undertake training in dementia care based on appropriate activities for service users with dementia care needs. Any person who prepares or handles food in the home is to undertake Food & Hygiene training, especially the cook whose certificate has expired. The minor maintenance areas identified in the main body of this report under ‘Environment’ must be addressed. A record of all meal prepared in the home especially the meals prepared for the service users in Hibiscus unit in the evening, which is different to the menu being offered. Legionella, gas and electrical installation certificate are to be in place. The recommendations addressed in the table at the back of this report are deemed good practice. 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.V291193.R01.S.doc Version 5.1 Page 9 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.V291193.R01.S.doc Version 5.1 Page 10 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, 3, 4 & 6 Quality in this outcome area is poor. This judgement has been made using evidence gathered both during and before the visit to this service. The home has breach their Conditions of Registration by admitting service users into the home, whose care needs are not apart of their overall registration. Therefore service users are being placed at risk of harm, as care staff are not skilled or experience to fully understand a number of individuals needs being placed. EVIDENCE: The home support up to forty-five service users over 65 years of age that may also have dementia care needs. It was evident from the discussion with the registered manager that a number of service users who currently reside in the home have mental health care needs. This was discussed a great length with the registered manager and the assistant managers on duty. It was evident that the home had been operating under these conditions for many years. During the inspection a care manager visiting one of the service users, informed the inspector that they were also under the impression that the home’s was able to support service users with a mental illness. It was therefore advised that at present the home is in breach of their Conditions of Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 11 Registration. Therefore an application to the Commission must be submitted for a major variation. It was also advised that until such time as the variation application has been process, the home should not admit any other service users in the home who care needs are mental illness. Care plans are fully reviewed every six months, and updated on a monthly basis by staff on the unit in which the service user lives. There was evidence of regular updating and review present on service user files were seen at this inspection. Hibiscus unit has been set up to provide care for elders from the Afro-Caribbean Community. However, service users with a mental health need assessments are not fully completed. The homes Conditions of Registration reflect that the Primrose Unit a ninebedded unit is to provide intermediate care for people aged over 65 years of age with dementia. However, since January 2006 this unit has been occupied by another care home within the organisation whilst their home is being refurnished. The manager also advised the inspector due to funding the unit may not be used for the purpose it was refurnished for this is still under discussion. At the previous inspection a requirement was made regarding the registered person amends the homes Statement of Purpose to include a section on the qualification of the registered provider. It was evident at this inspection this was not completed. Therefore this requirement is restated. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Service users health, personal and social care needs are set out in an individual plan of care. Evidence of updating information and changing action appears on individual care plan. However, this is not consistent monitored and reviewed. Therefore information regarding the individuals care needs maybe potential missed, resulting unmet needs. Service users can be confident that information about them is handled appropriately. The medication at this home is well managed promoting good health. EVIDENCE: Four service users care plans were examined. Service user plans are comprehensive and there is evidence of regular review and monthly updating as required. The care plans include where appropriate evidence of consultation with service users or their families. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 13 Each service user has a named key worker and the manager tries to ensure that each key worker is linked to service users with similar cultural differences to ensure continuity of care with regards to their cultural identity is maintained. The cultural identities of the service users within the home are varied and this matches with the staff team supporting. Daily logs are kept securely on each unit. Risk assessments are completed, but the overall level of risk is not always clearly indicated on the assessment that has taken place. Therefore it was not evident from the finding where the individual assessed was deemed low, medium or high risk. Therefore the care package in place might not be appropriate to meet that individual service user needs. The home has a good support network of professional visiting on a regular basis. The manager has a good rap pour with each of the professional visiting; this was evident at the time of the inspection as the district nurse and care manager visited. Service users weights are recorded monthly and any issues are raised with the GP. However, the weight charts were recorded in stones and kilograms, which seemed a bit confusing from the inspector’s point of view. It is recommended that the weight records should be completed in one format either stones or kilograms to ensure individual’s service users weight/s that may fluctuate can be appropriately monitored. All service users are registered with a GP. Access to other medical practitioners such as occupational health is made via GP referral. The GP has a surgery in the home once a week. If there are any other medical issues within the time of the next in-house surgery the home can contact the surgery directly. Service users with dementia or challenging behaviour have input from a named Community Psychiatric Nurses (CPN). Healthcare treatments and outcomes are recorded in the service user’s individual plan of care and reviewed on a continuing basis. The manager informed the inspector that one service user has palliative care due to their illness and the specialist nurse visits regularly. Records of falls were examined. Those service users, who were deemed high risk, did not have their care plans up dated nor had the home pulled together from the evidence written the risk element of the individual. In discussion with the manager it was evident that professional input is limited even when requested. It was advised that falls training with regards to prevention and intervention is needed for all care staff. The other area of support is for the home to liaise with the local falls clinic to ensure the ethos of care with regards to falls monitoring is seen as preventative and restorative. At the last inspection it was required that the registered person ensures 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 and care needs support. One service user file examined who was a Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 14 diabetic and it was evident that no information with regards to whether the individual diabetic was controlled or erratic was in place, although the district nurse made input. Therefore this required is restated. At the previous inspection an Immediate Requirement was issued regarding one specific service user’s medication. Prior to this inspection the Commission received an action plan stating the issue had been addressed. Medication was checked and found to be in good order. Medicines are stored appropriately under lock and key. Records of medicines received, administered and leaving the home are as required under this National Minimum Standard. Senior staff in the home that have received appropriate training from the local pharmacist only administers medication. Wandering around the home it was observed that service users were being treated respectfully and their dignity was upheld. One specific service user’s care plan was examined. It was evident that the specific individual has mental health care needs and can be challenging to staff and service users. On the day the manager had to challenged the individual on a health and safety issue, which the service user was not happy about, and wanted afterwards to raise a complaint with the social worker or some senior than the manager. The manager explained that some days are better than others with regards to the individual’s annoyance. However, issues around this specific service users health and care needs are not addressed in their care plan on a daily basis on how this is managed. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. Links with the community are good and support and enrich service users’ social and educational opportunities. However, the manager has failed to ensure that appropriate checks are in place for the staff that at times may support service users in the community. The food in this home is of good quality, well presented and meets the dietary needs of service users in the home. However, the manager has failed to ensure that the any staff that prepares or handles food in the home that their training needs are updated. EVIDENCE: Service users interests are recorded and they are given opportunities for stimulation through leisure and recreational activities in and outside the home, to suit their needs, preferences and capacities. A number of service users are independent and able to go out without support. The manager informed me that one service user at the time of this inspection was on holiday in Jamaica with their family. The home employs part time activity worker on a casual basis. The inspector on the day was able to speak to the activity worker with regard to their roles and responsibilities. It was evident from the discussion that the activity worker provides a weekly programme; however, it was only Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 16 displayed in the activity room. From discussion it was evident that the activity worker does one to one activities as well as group work. The planned activity for the day was a film afternoon in the activity room. The activity person organises the activities provided in the home and these are organised daily depending on individual service users needs. It was also evident during our discussion that the activity worker is employed by an agency and has been working at Broadwater Lodge for a number of years and during this time has not undertaken any course relating to working with individual with dementia or who may challenging at times. The question of supervision and Criminal Records Bureau (CRB) was raised and it was evident that supervision had not taken place and the manager has not seen a CRB certificate or had any details from the agency. It was reminded that supervision must take place with the activity person and the activity person current CRB enhanced certificate must be seen by the manager prior to the individual being employed. It was also recommended that it is good practice to have an individual daily activity log of activities undertaken by service users in the home. Two service users are allocated a day centre placement, however, the manager stated that they have refused to go. It was evident that individuals’ families and relatives visit regularly. The inspector was able to speak to two family members from the same family, regarding the care and support that their relative receives. From the discussion it was evident that they were very happy with the care and support provided by the home. They were also happy in the way their relative’s personal care has been supported appropriately according to the service user’s cultural needs and this was evident in their relative’s presentation. There have been a number of issues, which the home has handled appropriately, which the relatives are grateful for. The overall feedback was very positive. One area of concern related to service user’s mental health, which was appropriately handled, but they did have some questions of care staff understanding of their overall needs. The cook showed the inspector around the kitchen area. Three fire extinguishers were on the kitchen floor. The cook stated that the fire extinguishers had been replaced and those extinguishers on the floor were old ones that needed to be returned to the Contractors. The kitchen had been a redecorated, new fly screen; appropriate storage and procedures regarding labelling of food were in place. However, there were a number of opened, cooked or unrecognised foods in one of the fridges. The cook explained these items belonged to the care staff on duty. It was advised that any food left in the fridge must be clearly labelled especially food left by care staff. One specific cereal brought by the home in, bulk is stored in a large plastic container. The lid on this item was found to be loose and not well fitted. It was advised that the container is to be replaced. It was further recommended that the manager should consider purchasing this specific cereal in smaller portion sizes, rather than bulk this would eliminate any contamination and Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 17 wastage of food. Two of the fridges were ‘out of order’ on the day, the manager state at least one item will be replaced. On the day a contractor visited with regards to purchasing a new fridge for the home. The cook’s food and hygiene certificate was displayed on the kitchen wall it was evident that this certificate had expired. It was reminded that any person working in the preparing or handling food must have in place a current food hygiene certificate. Menus displayed in the kitchen showed a varied diet on offer, and that individual’s preferences are catered for, and four service users 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 special catering needs are met by the home. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Staff have an good knowledge and understanding of Adult Protection issues which protects serviced users from abuse. Service users have the confident that their complaints or concerns are listened to, taken seriously and acted upon. EVIDENCE: A copy of the complaints procedure is included in the welcome pack provided to new service users. During the inspection one of the service user complained to the manager about an issue regarding an item being removed from their bedroom. It was evident from the discussion with the manager that the item removed raised a number of health and safety issues. The individual wanted their complaint to raised with their social worker. The manager contacted the social regarding the complaint. It was evident from this the manager was handling the issue appropriately. It was also reminded that this issue must be documented clearly in the complaints log. It was evident from the training log that all staff have undertaken Adult Protection training. A copy of the Local Authority’s procedures was on file. However, policies and procedures relating to abuse on file needs to be update to coincide with current legislation that is place. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 19 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, 23 & 26 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Recent investment has significantly improved the appearance of this home creating a comfortable and safe environment for those living and visiting. EVIDENCE: The Broadwater Lodge is divided into smaller unit areas. 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 for Afro Caribbean. All units have been decorated to a high standard and are well maintained, which provides aids and equipment to meet the care needs of the service users. Each service users bedrooms are decorated also to a high standard and reflected individual style and taste. The home premises are suitable for its purpose. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 20 Since the previous inspection all the major refurbishment has been completed. The manager stated that there is a number of sagging only left to complete by the contractors. During the inspection a tour of the home was completed. The home was found to be bright, homely, comfortable and clean. However, there were a number of minor maintenance works that need to be address. • • • • • • Call point need the information with regard to the assembly points need to be completed Windows on the top floor need window restrictors in place The three fire extinguishers in the kitchen needs to be removed The portable phone in Rowan unit that is out of order, needs to be either replaced on repaired The health and safety notice needs to be completed The two fridges, in the kitchen area, that at present are not working are to be removed 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. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Service users are confident that the care staff supporting them on a daily basis are equipped with the right skills and experiences to manage and support them. EVIDENCE: Six staffing records were examined. The staff team consists of a 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 and two assistant managers. 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. At present vacancies are low. Recruitment is completed by the organisation and at present a number of homes within the organisation have closed. Staff from these premises have been redeployed to the Broadwater Lodge and other homes within the organisation. At the previous inspection the roles and responsibilities of the manager and assistant managers were discussed and it is the inspector views that the senior teams’ roles and responsibilities are overloaded and should be reviewed. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 22 A sample number of staffing records were examined. 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 and signed and dated by both parties. It was also evident that over 50 of the care staff have completed their NVQ level 2 and above, which was impressive. It was also evident from the findings that a number of care staff have been employed for a number of years and have been redeployed to several projects. Recruitment is completed centrally. The original copies of personnel information on kept at Head Office. A copy of the up-dated training programme 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.V291193.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using evidence gathered both during and before the visit to this service. The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Service users are confident that the home is run to the best of their interest. Service users are confident that staff are appropriately supervised and therefore competent to meet the needs of the service users whom they care for. Service users health and safety is regularly reviewed and monitored. Therefore, service users are fully protected and safeguarded. However, some areas of health and safety needs are to be regularly monitored to ensure these are kept up to date and within the requirements of the Law. EVIDENCE: The manager holds the an NVQ level 4 in Management and Care certificate and has a good understanding of, and familiarity with conditions and diseases Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 24 associated with old age. 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 service users was warm, with the manager showing a detail of knowledge about each individual service user. Records examined indicated that staff meetings are generally held separately for day and night staff every 6 weeks. There are regular service users meetings. It was evident that the commitment is made to ensure equal opportunities and meeting individual’s diverse needs is a part of the whole ethos of the home policies and procedures. The effective quality assurance and quality monitoring, based on seeking the views of service users has been completed in 2005. However, the results of the process have not been made official or documented, as the findings were only based on service users views. It is therefore required that the results must be available as part of the home’s annually feedback and views must be sought also from family and friends and any stakeholders involved in the care of the service users. The majority of service users either control their own money or have their financial affairs managed by their families. However, the administrator for the home was off at the time of this inspection, therefore the Standard 35 was not inspected. Formal supervision is completed regularly and covers all aspect of practice, philosophy of care in the home and developmental needs. Record keeping in the home has improved since the previous inspection. Individual records and the home records are secure, up to date and in good order in accordance with the Data Protection Act 1998. However, it was evident that a number of policies and procedures were out of date and these need updating in to be in line with current legislation. 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. However, no Legionella, gas or electrical installation certificates were present. Safe storage and disposal of hazardous substances are in place. At the previous inspection it was required that the registered person completes an environmental risk assessment, which includes a fire risk assessment. At this inspection this was in place. Training around moving and handling, food hygiene, fire safety first aid and infection control is always updated by the organisation to ensure staff are well adverse in the practice of keeping the service users and themselve safe in the home environment. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 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 2 X 1 3 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 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 3 X 3 X 3 X 2 2 Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 26 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 OP3 Regulation 14(1) Requirement The registered person must submit an application to the CSCI regarding a major variation to accommodate the service users who at present reside in the home with a mental health disorder. The registered person must cease the practice of admitting any service users with mental health problems into the home until such time as the application for variation has been approved by CSCI. The registered person must amend the homes Statement of Purpose to include a section on the qualification of the registered provider. Previous timescale of 20/03/06 not 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 DS0000033332.V291193.R01.S.doc Timescale for action 20/07/06 2. OP1 4(1)(c) Sch 1.2 30/07/06 3. OP8 17(1a) Sch 3(3m) 30/07/06 Broadwater Lodge Version 5.1 Page 27 place. Evidence is to be recorded on the individuals care plan. Previous timescale of 20/03/06 not met. The registered person must seek advice and guidance from the relevant professional with regards to managing service users who are deemed high risk of falling. Evidence of this is to be kept on file. Any changes must be reviewed accordingly. 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. Previous timescale of 20/03/06 not met. The registered person must ensure that risk assessments are fully completed to ensure the correct risk level of risk is recorded on each service users care plan. The registered person must ensure that the service users who are diagnosis with a mental health illness have in place a clear and comprehensive care plan that is specific to their mental health needs. Such as hoarding, challenging and habits that may interfere with the normal day to day routines of the home. Each care plan must include how the home supports the individual and how this is monitored and reviewed. The registered person must ensure that the complaint regarding the specific service DS0000033332.V291193.R01.S.doc 4. OP8 17 Sch 3(m) 30/07/06 5. OP8 14(2) 30/07/06 6. OP8 15(1)(2) 30/08/06 7. OP8 15(1)(2) & 22 30/07/06 Broadwater Lodge Version 5.1 Page 28 users and the action taken is clearly documented on the individual’s care plan. The registered person must ensure that the specific service users care plan clear addresses all the individual care needs that pertains to their mental health and how this is supported by the how and any outside professional involved in the individual’s care. The registered person must 20/08/06 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. Previous timescale of 20/02/06 not met The registered person must ensure that a thorough risk assessment is completed for each service users who is supported by the activity person on any external outing. The registered manager must 30/07/06 update the medicines policy and include a section dealing with the possibility of disguising the medication, if non-administration will seriously endanger a service user’s health. Previous timescale of 30/04/06 not met The registered person must 30/07/06 ensure all staff employed, such as agency workers, has in place before commencing work in the home an Enhanced Criminal Record Bureau (CRB) check that has been completed by the agency. Evidence of this must be in place before the individual starts employment. The registered person must 30/07/06 DS0000033332.V291193.R01.S.doc Version 5.1 Page 29 8. OP7 15 9. OP9 13(2) 10. OP12 19 Sch 2.7 11. OP12 18(2) Broadwater Lodge 12. OP12 18(1)(c)(i ) undertake at least six times a year supervision with the activity person and records of this must be kept on file. The registered person must ensure that the activity worker undertakes training in dementia care based on appropriate activities for service users with dementia care needs. The registered person must ensure that any person who prepares or handles food in the home is to undertake Food & Hygiene training, especially the cook whose certificate has expired. The registered person must ensure that the three extinguishers are removed from the kitchen area. The registered person must either remove or replace the two fridges that are ‘out of order’. The registered person must ensure that the any open food kept in the fridges are clearly labelled this includes food brought by staff into the home. The registered person must replace the large dried food storage containers that was broken. The registered person must kept a record of all meal prepared in the home especially the meal prepared for the service users in Hibiscus unit in the evening which is different to the menu being offered to the other service users in the home, and that it is balanced and nutritious The registered person must ensure that the abuse policy is update. DS0000033332.V291193.R01.S.doc 30/08/06 13. OP15 13(4) & 23(2)(c) 30/07/06 14. OP15 13(4) 30/07/06 15. OP15 17(2) Sch 4.13 30/07/06 16. OP37 17 30/08/06 Broadwater Lodge Version 5.1 Page 30 17. OP38 13(4) 18. OP19 13(4) 19. OP19 23 The registered person must ensure the water supply (water Fittings) Regulation 1999 with regards to Legionella, gas and electrical installation certificate. The registered person must have in place clear signage that helps visitors’ to the home enter the building safely. Previous timescale of 28/02/06 not met The registered person must ensure that the • Call point instruction are clear completed • The windows on the top floor have appropriate • The window restriction in place in • The three fire extinguishers in the kitchen are removed • The portable phone in Rowan unit is replace or repaired • The health and safety notices is to be completed • The two fridges in the kitchen must be either removed or replaced. 30/07/06 30/07/06 30/08/06 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. It is recommended that the registered person should ensure service users monthly weight records are recorded in either stones or kilograms to ensure that if individual’s weights fluctuate this can easily be identified and the DS0000033332.V291193.R01.S.doc Version 5.1 Page 31 Broadwater Lodge 3. OP15 appropriate action taken. It was recommended that the registered person should consider purchasing the specific cereal as addressed under ‘ Life and Social Activities’ into smaller portion sizes, rather than bulk this would eliminate any contamination and wastage of food. Broadwater Lodge DS0000033332.V291193.R01.S.doc Version 5.1 Page 32 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.V291193.R01.S.doc Version 5.1 Page 33 - 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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