Inspection on 08/04/05 for Broadwater Lodge

This inspection was carried out on 8th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 26/11/07

Broadwater Lodge 02/07/07

Broadwater Lodge 09/08/06

Broadwater Lodge 23/08/05

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 Summers Road Farncombe Surrey GU7 3BF Lead Inspector Mrs V Bulbeck Unannounced 08 April 05 10:00 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Broadwater Lodge Address Summers Road Farncombe Surrey GU7 3BF 01483 414186 01483 422232 manager.broadwaterlodge@careuk.com Care UK Community Partnerships Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Susan Jane Cripps Care Home (CRH) 50 Category(ies) of Old age, not falling within any other category registration, with number (OP), 6 of places Dementia - over 65 years of age (DE(E)), 44 Sensory impairment over 65 years of age (SI(E)), 3 Physical disability over 65 years of age (PD(E)), 4 Broadwater Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 2 persons may be aged 60-65 years in the categories PD or DE. 2. Up to 10 persons may be admitted to the home for short stays only. Date of last inspection 16th August 2004 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, each unit caters for 10 residents. All bedrooms are of single occupancy and each unit has its own bathroom, toilet, 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. Broadwater Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 9 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. Vera Bulbeck, Lead Inspector for the service, carried out the inspection. Miss Susan Cripps, Registered Manager, was present as the representative for Broadwater Lodge. There are currently 50 service users living in the home with 42 long term and 8 short term (respite care). A full tour of the premises was undertaken. 10 care plans were observed and three staff files were inspected. 9 members of staff were spoken with during the inspection as well as thirteen residents and two relatives. What the service does well: The home has a statement of purpose and service users guide which sets out the aims an objectives and facilities of the home. Service users are admitted to the home following a full assessment, which is undertaken by a qualified member of staff. The home has a stable and committed staff team. Some staff commented they are supervised and supported and are able to speak with management at any time. The inspector spoke with thirteen residents who gave positive feedback with regards to the care they receive and stated that the staff are kind and helpful. One service user stated that “the home is like a hotel”. A number of residents were unable to communicate and the inspector observed the interaction between staff and service users to be good. On one unit a member of staff was sitting painting a service users nails, who was clearly enjoying the attention received. The home has a committed fund raising group, and money is used to finance entertainment and various outings. Broadwater Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broadwater Lodge Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Broadwater Lodge Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 Residents are admitted to the home following a full assessment undertaken by staff trained to do so. The registered manager was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The home had a comprehensive statement of purpose, which accurately reflected the services provided by the home. Service users were very complimentary about the care they received and stated the home meets all their needs. A full assessment is undertaken of all potentially new residents to the home, and risk assessments for individual residents were seen. A written contract and terms and conditions were observed on resident’s files. The registered manager stated there are plans to increase the beds by 16 service users; all beds have been allocated in advance. The registered manager and Senior Care member of staff were able to demonstrate that the home had the capacity to meet the assessed needs of older people requiring personal care as stated in the statement of purpose. This will need to be updated when the beds are increased. These include the Broadwater Lodge Version 1.10 Page 9 provision of adaptations and equipment such as assisted baths, hoists and wheelchairs. Prospective resident’s are invited and encouraged to visit the home, stay for the day and talk with existing resident’s. The home provides trial periods of up to four weeks, and the period of time can be extended if requested. Broadwater Lodge Version 1.10 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Health, personal care and social care needs are being met in the home. EVIDENCE: Care plans were found to be well documented and indicated that resident’s health care needs are being met. The G.P provides a medical history of each resident. A dietitian is involved particularly with one resident who lost weight. Each resident has an individual care plan and records seen suggested that residents and family are involved with their care plan. There are currently no residents who self medicate and the homes policies and procedures have recently been up dated. The registered manager stated that senior staff who are trained to do so administer medication. Signatures of staff administering medication were found in the front of the medication charts. Positive comments were made from residents about the care they receive and confirmed the “staff look after them well”. A number of residents commented on the home and staff being wonderful, caring and kind. Staff was observed to interact in a respectful manner with residents, particularly those with dementia. Broadwater Lodge Version 1.10 Page 11 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 standard(s) 12,13,14 and 15 There are systems in place to involve resident’s in their daily routine. Regular resident’s meetings take place and resident’s views are both sought and acted upon. EVIDENCE: Every two months a church service takes place in the home and all denominations are taken into consideration. Entertainment in the home is organised on a regular basis. There are a variety of activities, for example, music and dancing was popular, and next month a V.E. party has been organised. Outings to Godalming for shopping and pub lunches are always popular. The homes budget covers the funding for extra staffing for escorting resident’s. Various types of transport are hired. The activity organiser is new in post and is currently on her induction programme and is learning from the day care activity organiser already in post. The majority of resident’s have contact with family and friends. Representatives and assistant social workers visit monthly to three allocated resident’s. All the resident’s have a care manager, including the privately funded resident’s. Reviews are undertaken on a six monthly basis. All resident’s are able to make choices and have control regarding their life style, for example what time they get up and go to bed, and choice of meals every day. Resident’s confirmed they could do what they like within reason. Broadwater Lodge Version 1.10 Page 12 The meal time arrangements were adequate: there is a choice of two main meals, (a vegetarian meal or as an alternative an omelette), as well as a choice of desserts. There are meals available for special diets, diabetic, low fat and multi cultural meals are also provided for when requested. The meals being served on the day of inspection were observed to be wholesome and nutritious. Broadwater Lodge Version 1.10 Page 13 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 standard(s) 16,17 and 18 The home has a well-documented complaints system, which was working well, and made available to all residents and staff. EVIDENCE: Resident’s confirmed they know how to make a complaint and would feel happy to tell their key worker if necessary. Some residents stated that they would tell their family first. Management of the home has received seven complaints since the last inspection. All seven have been dealt with appropriately and records were observed to be well documented. The majority of staff have received protection of vulnerable adults (POVA) training. Broadwater Lodge Version 1.10 Page 14 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 standard(s) 19,20,21,24,25 and 26 The home was found to be homely, nicely furnished and decorated. The standard of cleanliness around the home was good. Staff are to be congratulated on this achievement. EVIDENCE: Since the last inspection all units have had new kitchen units fitted and a door leading into the kitchen has been fitted, for the safety of the resident’s. One resident commented the “home is like a hotel”. There are plans to increase the number of beds in the home by 16. There were a few areas around the home that require attention. The radiators require safety covers and this has been a requirement since the previous inspection. One of the resident’s bedrooms was without a shade. It was noted that a number of door handles were loose and some fire doors were not closing appropriately. The inspector noticed that in one of the resident’s bedrooms there was a vase of dead flowers without water. It was also noted that resident’s are currently without a lockable facility in their bedroom. Broadwater Lodge Version 1.10 Page 15 The kitchen staff toilet needs to be cleared of items stored and must be useable for the kitchen staff. The inspector was informed the dishwasher in the main kitchen is nearly new and has broken down a number of times resulting in staff having to wash up by hand. This item should be examined as to why it constantly breaks down. It was also noted a number of bins around the home were without lids. On Nightingale unit a toilet was found to be locked and staff informed the inspector the toilet was blocked and out of order since Monday 4th April. The maintenance person stated he had unblocked the toilet on Tuesday 5th April. It was not known who had kept the toilet locked for 4 days resulting in resident’s not able to use. Regular checks of the premises should be maintained and any work to be undertaken by the maintenance person should be recorded and signed when the work has been undertaken. The grounds and garden areas are well maintained, however, items stored in the rubbish area need to be disposed of. A tap was found to be dripping on one unit, and a bathroom was found to have a number of items stored and currently the bathroom was not in use. Sluice areas were observed to be open and need to be kept locked at all times to ensure the safety of residents. The home was found to be clean and comfortable for the resident’s. There is a daily cleaning programme in place. Bedrooms were personalised and each unit was named after a bird with a plaque on each bedroom door with the residents name on. A number of bedrooms had been partly furnished with residents own belongings. The 16 new bedrooms being built will have ensuite facilities. There are plans to build a conservatory on each unit and new fencing to be erected completely around the home. Broadwater Lodge Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 There were competent and trained staff employed to support residents and who were aware of the changing needs of each individual person. EVIDENCE: There are currently two staff on each unit owing to the recent recruitment of new staff and the induction process although this is not standard practice across all the units. The normal ratio of staff is eight care support workers in the morning and a team leader, and in the afternoon there are seven care staff on duty. In view of the proposed increase in the number of residents the staffing levels will need to be reviewed. Full recruitment procedures are being followed. All staff have been checked against the Criminal Records Bureau (CRB) before working in the home. Staff records were observed and found to be well documented, including contracts and terms and conditions. Training has been ongoing and the majority of staff have attended a number of training courses. However, the training plan needs to be kept up to date. All new staff receives a three to four day induction training programme, two days are in house training which covers dementia care and (POVA) protection of vulnerable adults and is undertaken by the team leaders. A number of training courses have been completed these include, bereavement, food hygiene, moving and handling, health and safety, first aid. Broadwater Lodge Version 1.10 Page 17 Twelve members of staff have completed NVQ’s, five staff have completed NVQ Level 3 and seven staff have completed Level 2. There are more staff currently undertaking NVQ’s. Broadwater Lodge Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36 and 38 Staff confirmed that the registered manager has clear and consistent leadership skills, and all staff illustrated an awareness of their roles and responsibilities. EVIDENCE: The registered manager is experienced and capable of managing the home, and is in the process of completing the Registered Managers Award. Staff are supervised on a regular basis and goals are set for training needs and identifying how the home can improve the care provided. All staff receive supervision every two months by the registered manager. Team Leaders are shortly to undertake the training required to supervise care staff. The administrator deals with resident’s bank accounts and personal allowances. Care UK Finance department audits the home on a regular basis Broadwater Lodge Version 1.10 Page 19 and financial procedures are in place and monitored. Resident’s family/relatives are involved with the resident’s finances, and receive a statement on a regular basis. There are also regular monthly visits by a designated person to undertake a quality audit of the home in line with statutory requirements. A number of records were observed and found to be well documented these include the accident book, fire records, training, residents and staff meetings; as well as health and safety records. However, the recent Environmental Health Officer report identified a number of requirements still outstanding on the day of inspection. The ceiling and walls in the kitchen were in need of cleaning, and all dried food should be stored in plastic containers with a lid. There is also a broken fridge stored in the kitchen and staff informed the inspector the fridge has been broken for some considerable time. It was noted that some bathrooms and toilets had bars of soap without being in a soap container. This practice is a health hazard and open to cross infection. Broadwater Lodge Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 2 3 2 x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 3 3 3 x 2 Broadwater Lodge Version 1.10 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. Standard 25 19 19 19 21 38 Regulation 13 13 23 23 23 13 Requirement All radiators must have appropriate guards. All dried food must be appropriately stored in a sealed plastic container. The ceiling and lights in the kitchen must be cleaned A number of loose door handles require repair The kitchen staff toilet must be cleaned and cleared of rubbish Bars of soap must not be left in bathrooms and must be contained in an appropriate soap holder with a lid. All bins must be provided with lids A shade was missing in a residents bedroom and must be replaced Toilets out of order must be attended to immediately. The broken fridge in the kitchen must be removed. The Environmental Health report requirements and recommendations must receive action Timescale for action 08/07/05 15/04/05 29/04/05 11/04/05 11/04/05 11/04/05 7. 8. 9. 10. 11. 19 24 21 38 38 13 16 23 23 16 11/04/05 11/04/05 11/04/05 11/04/05 29/04/05 Broadwater Lodge Version 1.10 Page 22 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. 4. 5. 6. 7. 8. 9. Refer to Standard 19 24 25 22 30 38 38 38 16 Good Practice Recommendations Dead flowers in a vase should be disposed of. A tap was found dripping on Skylark and should receive attention All radiators should be working and not switched off unless there are specific documented reasons for doing so (including risk assessments) A bathroom to be cleared of items should not be in a bathroom. The training plan to be up to date. Sluice rooms to be locked at all times. The dishwasher to be inspected as to why it constantly breaks down. The rubbish and old furniture in the garden needs to be cleared. Lockable facilities to be provided in all bedrooms.(from the last report has not been implemented.) Broadwater Lodge Version 1.10 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Version 1.10 Page 24 - 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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