Inspection on 09/08/06 for Broadwater Lodge

This inspection was carried out on 9th August 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 26/11/07

Broadwater Lodge 02/07/07

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 Sandra Holland Unannounced Key Inspection 13:00 9th August 2006 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.V302223.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.V302223.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.V302223.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 2 (two) persons may be aged 60-65 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 23rd August 2005 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.V302223.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced “key” inspection was the first to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007, and was carried out under the CSCI Inspecting for Better Lives programme. As the inspection was unannounced, no-one at the home knew it was to take place. Mrs Sandra Holland, Lead Inspector carried out the inspection over two days, 9th and 11th August 2006, a total of nine and a quarter hours. This was because all the required information could not be gathered on the first day. Miss Susan Cripps, Registered Manager was present representing the service. All areas of the premises were seen and a number of records and documents were examined, including care plans, medication administration record (MAR) charts and staff files. Ten service users, four visitors, one healthcare professional and nine staff were spoken with during the course of the inspection. A pre-inspection questionnaire was supplied to the home and this was returned to CSCI once completed. Some of the information contained in the questionnaire will be referred to in this report. What the service does well: The home is very well presented and generally freshly aired, which is admirable given the high needs of many of the service users. Service users are encouraged to be as independent as possible. Visitors and service users spoke of the kindness of staff and visitors said they are made welcome to the home. Staff make good efforts to communicate with service users, including those for whom English is not their first language. Staff receive a range of training to enable them to carry out their role. Night care plans have been completed, to guide staff to service users nighttime preferences. Service users’ healthcare needs are well met. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 6 The home is well equipped with allocated rooms for activities and staff training and a useful shop and tea bar. What has improved since the last inspection? What they could do better: Contracts or statements of terms and conditions must be provided to service users and the contracts in use by the home should be reviewed. Care plans (including night plans), must be fully completed and assessments of risks to service users must be more detailed. Adequate stocks of prescribed medication must be maintained, to ensure that these are available to service users and doses are not missed. The receipt of medications into the home must be recorded and must include the quantity of medication received. The social and leisure activities and staffing hours for these need to be reviewed to ensure they are sufficient to meet the needs of service users. All the required records and documents must be obtained before a person is permitted to work in the home. The details of the records and documents obtained must accurately correspond. A summary of the survey about the quality of the service provided by the home must be made available to service users and forwarded to CSCI. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 7 The home must be kept free of hazards to the safety of service users and the premises must be kept secure. The back door must not be propped open. 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 DS0000013892.V302223.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.V302223.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some, but not all service users have been provided with contracts. The needs of service users are assessed before they move into the home, but some of the assessments have not been signed or dated. EVIDENCE: From the records seen, it was clear that most, but not all, of the service users have been provided with a contract detailing the terms and conditions for living at the home. It was noted that the home’s contracts did not specify the starting date of the period to be covered and for one service user, the room to be occupied was not stated. It is recommended that the wording of the home’s contract is reviewed and revised. At one point the contract states that “residents must ensure that a full assessment of their needs has been carried out by people trained to do so and the outcome of that assessment reported to the home”. It is the responsibility of the home, not the service user, to ensure that an assessment Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 10 of their needs has been carried out. It is also the home’s responsibility to assure a prospective service user that their needs can be met. The manager advised that a number of service users are financially supported by local authorities. It was noted that for these service users, a copy of the terms and conditions of the agreement between the home and the appropriate local authority, were not held, as is required. The files of four recently admitted service users were seen and a pre-admission needs assessment had been carried out for each. Of the four pre-admission assessments, one had been signed and dated, but the others had not, so it is not possible to know when these were carried out or by whom. Three of the pre-admission assessments had not been fully completed. It is required that all areas are completed, signed and dated. It is recommended that those parts of the assessment that do not apply should be marked as not applicable, to indicate that those areas have been considered and were not overlooked. It is a requirement that pre-admission assessments are carried out by staff who are suitably qualified or suitably trained, but it is not clear which staff have carried out the assessments mentioned above. The manager stated that the home does not provide intermediate care. A requirement and a recommendation have been made regarding Standard 2. Broadwater Lodge DS0000013892.V302223.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are drawn up for each service user, but these need to be fully completed and reviewed each month. Service user’s healthcare needs are well met. The quantities of medication received into the home must be recorded and service users must not be left without access to their prescribed medication. EVIDENCE: As mentioned previously, the individual files for four recently admitted service users were seen. These included the care plans and assessments of any risks to service users. The care plans are used to inform and guide staff to the care and support needs of each service user. For a number of service users, the information in their care plan was not complete or had been entered up to six weeks after the service user was admitted. It was pleasing to note that the night care plan had been completed with detailed information regarding the service users sleep pattern and preferences at night. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 12 Where risks to service users have been identified, these have been assessed and recorded, but it was noted that these records did not provide any guidance to staff as to any measures that could be taken to minimise the risks. It was noted that the report from a Regulation 26 visit to the home in May this year had highlighted the need for care plans to be reviewed and updated monthly, including night care plans. The report also stated that care plans must reflect any changes or risks which are noted, and gave the example of weight gain or loss. It was noted that one service user had lost a considerable amount of weight since admission, but this was not reflected in the care plan, so it was not clear whether this was intentional, desirable or indicated that the service user was ill or not being fed well enough. Regulation 26 requires organisations which are not in direct day-to-day control of a care home, to nominate someone to visit the home, on a monthly, unannounced basis. The visitor is required to speak to service users and staff, to look around the premises and to write a short report on their findings, a copy of which should be held in the home. From the records seen and speaking to visitors, it was clear that service users healthcare needs are well met. Timely and appropriate referrals are made to healthcare professionals, a number of whom are involved in the support of service users. These include general practitioners (GP’s), community nurses, community psychiatric nurses (CPN’s) and chiropodists. The administration of medication is appropriately managed overall, although two shortfalls in the required standard were noted. Medication is administered by staff trained to do so and an individual trolley is used to store the medication for each of the five units. Two air-conditioned medication rooms are available to ensure medication is stored in a locked provision and at the correct temperature. Each medication room is fitted with a fridge specifically for storing medication requiring chilled storage. It was observed on a MAR chart, that a prescribed medication for one service user had been out of stock for four days, which resulted in the service user missing the prescribed doses. It was also noted that the quantities of medication are not recorded when medication is received into the home. It is therefore impossible to check that the amounts of medication accurately match the record held, or to follow an audit trail. A monitoring visit by the supplying pharmacist two days prior to the inspection, identified that medication received into the home needed to be recorded on the MAR chart. Staff were observed to speak to service users in an informal, but appropriate manner and personal care was provided in a way that promoted service user’s privacy and dignity. Staff were seen to offer service users kindly support and gentle encouragement. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 13 A requirement has been made regarding Standard 7 and an immediate requirement has been made regarding Standard 9. Broadwater Lodge DS0000013892.V302223.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities staff and facilities are available, but the hours provided for these need to be reviewed. Service users are supported to maintain their community contacts. A wholesome and well-balanced diet is provided. EVIDENCE: A large and well-equipped, designated activities room is available at the home. This is furnished with tables and chairs, armchairs, music facilities and a television and storage for a range of activity materials. Art work was displayed around the room and it was pleasing to see a number of photograph albums and scrapbooks featuring service users. The manager stated that a full-time member of staff is employed as an activity co-ordinator and she is assisted for ten to twelve hours each week by a member of staff, who is employed in another role at the home. Both of these staff work primarily Monday to Friday, the assistant member of staff advised. An activities programme was displayed on the activity room door and this was seen to be a chart in the form of coloured bars representing the different activities that were to take place on different days. This was difficult to understand and it is strongly recommended that this is reviewed and presented in a format that is suited to the needs of the service users. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 15 It was noted that on both visits to the home, the activities co-ordinator was not present and no organised activities were taking place. Most service users were observed to be sitting in the lounge or communal areas, with little effective, meaningful stimulation taking place. A musical video was being shown in the lounge area of one unit on the second visit to the home. As most of the service users at the home have dementia and many require a significant amount of assistance to take part in activities, the staffing hours for this role need be reviewed, to ensure they are sufficient to meet the social and leisure needs of service users, including at weekends. It was clear from speaking to service users and visitors, that service users are supported to maintain contact with their families and friends. One service user was spoken with as she waited to go out for lunch with her family and other visitors spoke of the welcome they receive at the home. Visitors advised that they are kept informed of any changes affecting their relative, or if they are unwell. Staff advised that they offer choices to service users and support them to make decisions. Examples were given of offering service users a choice of the clothes they would like to wear, the food they would like to eat and where they prefer to sit. Staff stated that if service users are not able to communicate verbally, staff observe service user’s facial expressions and body language to assess their responses. It was pleasing to note that one service user with specific language needs has been assisted by a member of staff who also speaks the same language. A number of useful words have been provided by the staff member to help other staff communicate with the service user. A number of nations are represented amongst the staff team, although this is not reflected in the service user group. Staff advised that they have undertaken equality and diversity training and that the home treats everyone equally and welcomes diversity. A four week menu was supplied with the pre-inspection questionnaire and this was seen to be well-balanced and wholesome. Two main course dishes and a vegetarian option are offered each day, and these are available in alternative forms, such as pureed, for those service users requiring this. Catering staff advised that service users are asked each day to make their selection for meals the following day, and that provision was made for specialist diets, such as vegetarian and diabetic diets. Meals are served in the dining areas of the individual units in the home and tables were seen to be attractively set with table-cloths, napkins and flowers. Staff were attentive and available to help those service users requiring assistance and this was provided discreetly. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 16 A recommendation has been made regarding Standard 12. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are effectively managed and staff are aware of their responsibilities in the protection of service users. EVIDENCE: The manager stated that numbered complaint forms are used to enable these to be audited. The forms are kept in the team leaders office and are freely available, but anyone wishing to record a complaint would have to request a form. As this prevents anyone making an anonymous complaint, should they wish to, it is recommended that the forms are made openly available, along with the complaints procedure. The complaints record was seen and it was noted that a number of complaints had been made this year, some referring to similar concerns. This was discussed with the manager, who advised that these issues had been raised with staff at staff meetings. It is recommended that the manager review the complaints made to ensure that any recurring themes can be addressed and monitored. From speaking to staff it was clear that they were aware of their responsibilities in the protection of service users. Staff advised that they had undertaken training in the protection of vulnerable adults and were aware of the home’s whistle-blowing policy. In the event of any abuse or suspicion of abuse, staff stated that they would report their concerns to the manager or Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 18 team leader. If necessary, they would report any concerns to the area manager who visits the home regularly and is known to staff. A recommendation has been made regarding Standard 16. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 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, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a comfortable place to live and a good standard of hygiene is maintained. EVIDENCE: The home is a purpose built property and has recently been extended to add a further seventeen bedrooms with en-suite facilities and two smaller lounges. The home is divided into five units, each with its own lounge and dining area and kitchenette. All areas of the home were seen and were tidy and well presented. Enclosed areas of the garden are available to service users and tables, chairs and sun umbrellas were provided. Staff advised that few of the service users are able to use the garden unaided and most are assisted to access the garden or patio areas. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 20 Service users’ rooms were individually decorated with co-ordinating soft furnishings. Service users spoken to stated that they have been offered a key to their bedroom. One service user stated that she has a key and usually prefers to keep her room locked, although she did not have any concerns regarding security. Staff advised that a number of service users are not able to retain a bedroom key due to the level of their dementia. It was pleasing to see that service user’s bedrooms had been personalised with photographs, pictures, small items of furniture and ornaments. Each room is equipped with a lockable provision for the storage of valuables. Some service users have had a telephone installed in their room to enable them to keep in touch with their families and friends. The home was clean and appeared hygienic. Hand-washing facilities are provided at appropriate places and are equipped with liquid soap and paper towels. A colour coded system is used to ensure that cleaning equipment is used in the designated areas, to prevent cross infection. Staff were seen to use personal protective equipment, including gloves and aprons. Most areas of the home were freshly aired, which is admirable given the very high continence needs of many of the service users. Just two areas needed improved odour control, these being one bedroom and the communal area of one unit. A large, well-equipped laundry with separate ironing room, is positioned away from the residential units of the home. It was noted that despite the use of an entry-phone system at the main entrance, the premises were not kept secured, as another door marked “to be kept locked”, was propped open. This is referred to at Standard 38 which refers to health and safety matters. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A stable and well-trained staff team is employed to meet the needs of service users. Recruitment practices must be more robust to fully protect service users. EVIDENCE: From the information supplied with the pre-inspection questionnaire, it was clear that a stable team of staff are employed to meet the needs of service users, many of whom have worked at the home for two years or more. The staff team consists of care staff, housekeeping staff, kitchen staff, laundry staff, maintenance staff, an activities co-ordinator and an administrator, all working under the leadership of the manager. As mentioned at Standard 12, it is required that the working hours of activities staff are reviewed, to ensure these are sufficient to meet the needs of service users. It was noted that the activities co-ordinator was not present on either of the inspection days and most of the service users were not receiving any meaningful stimulation. Staff advised that activities staff do not currently work at weekends, although the service users have a high level of needs because of their dementia, and these are no less at weekends. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 22 The team leader advised that a number of care staff have undertaken National Vocational Qualifications (NVQ’s) in care to level 2 or above. A further group have recently been registered to undertake NVQ’s in the near future. The standard of recruitment practices at the home need to be more robust. This was a requirement from the last inspection carried out on 23rd August 2005, and has not been met. Although most, but not all, of the required information and documents had been obtained for staff employed to work at the home, the information on some of the documents did not correspond with that on others. For one member of staff, an application form was present in one name, although other documentation was present in another name. For another member of staff, the two references obtained appeared to have been obtained after the person had started work. The manager explained that the start dates recorded on the person’s contract of employment and the payroll list were incorrect. A reference for a member of staff had been supplied in a foreign language and no translation was available, so it was not possible to know what information had been provided. For two members of staff, a full employment history had not been obtained. Staff training at the home appears to be well managed. One of the team leaders takes the lead for monitoring and planning training and a designated training room available. A training plan and record is maintained and is displayed on the wall of the training room. Each member of staff has their own training file, to record training undertaken and to hold certificates. Staff spoke enthusiastically about training in the home saying that “training is really good here”. From the records seen it was evident that staff had undertaken training required by law, such as fire safety, first aid and food hygiene as well as training to develop their knowledge and skills, including dementia training and infection control. Requirements regarding Standard 27 and 29 have been made. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and experienced to run the home and service users’ finances are managed appropriately. The summary of the quality survey needs to be supplied to service users and CSCI and attention needs to be paid to aspects of health and safety. EVIDENCE: The manager stated that she has managed the home for many years, is a qualified nurse and maintains her nursing registration. The manager advised that to develop her knowledge and skills, she has been undertaking the NVQ Registered Manager’s Award, which is almost complete. The manager was seen to interact informally with service users and to be approachable to staff. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 24 A review of the quality of the service provided has been carried out the manager advised, but as a copy of the results has not been supplied to CSCI or made available in the home, the manager agreed to forward this. The administrator advised that monies are held for safekeeping for a number of service users and that receipts are provided for deposits and withdrawals. Service user’s monies are all held individually and when these were checked with the record held, all accurately matched. It is required that a number of records relating to health and safety in the home, must be maintained. From the information supplied with the preinspection questionnaire, these are being carried out to the required frequency. It was noted that the kitchen cleaning schedule which is maintained, had not been signed during the last week of July. The kitchen staff stated that the cleaning had been carried out, but signing the record had been overlooked. The kitchen appeared clean and orderly on the day of inspection. The home’s accident records were seen. These are recorded on individual, numbered forms which conform with data protection requirements, and are stored in month order for ease of reference. As mentioned at Standard 19, the security of the premises was not being maintained, as it was observed that a rear door near the staff room was propped open with a chair, despite being marked with a sign that stated “to be kept locked”. As this opens directly onto the driveway which leads to the front of the home, this is a potential hazard, both to service users who may attempt to leave the premises and to all in the home, as an intruder could gain unauthorised access to the home. Two other potential hazards were noted during the tour of the premises, but both were addressed immediately. A television was observed stored on the floor in the communal area of one of the units and the team leader requested staff to remove it. A bathroom floor had been washed and a bucket was used to block the doorway, but this was replaced immediately with a yellow “wet floor” warning sign. A requirement has been made regarding Standard 38. Broadwater Lodge DS0000013892.V302223.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 2 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x 3 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 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 OP2 Regulation 5 Requirement Contracts or the terms and conditions of residence at the care home, must be supplied to service users. Pre-admission assessments of the needs of service users must be fully completed, signed and dated by the person carrying out the assessment. The assessments must be carried out by suitably qualified or suitably trained persons. Service users’ care plans must be fully completed with the required information. Unnecessary risks to the health or safety of service users must be identified and so far as possible eliminated. Assessments of risks must clearly detail the risks and the control measures to be taken to minimise the risks. Complete and accurate records must be kept of all medication administered to service users. Service users must not be left without a supply of prescribed medication and the receipt of DS0000013892.V302223.R01.S.doc Timescale for action 08/09/06 2 OP3 14 11/08/06 3 4 OP7 OP7 15 13 (4) (c) 08/09/06 08/09/06 5 OP9 13 11/08/06 Broadwater Lodge Version 5.2 Page 27 medication into the home must record the quantity received. 6 OP12 16 Timescale of 30/08/05 not met. The provision of activities in the 10/11/06 home must be reviewed to ensure they meet the needs of service users. The number of hours to be 10/11/06 worked by activities staff must be reviewed to ensure they are sufficient to meet the needs of service users. Full recruitment details must be 11/08/06 obtained and be available in the home at all times, including application forms and references. Timescale of 2/08/05 not met. The summary of the quality assurance survey carried out must be made available to service users in the home and a copy forwarded to CSCI. The home must be conducted so as to promote and make proper provision for the health and welfare of service users. Specifically, the security of the care home premises must be maintained. 10/11/06 7 OP27 18 8 OP29 19 9 OP33 24 10 OP38 12 11/08/06 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 OP2 OP12 Good Practice Recommendations It is recommended that the home’s contracts are reviewed and revised to amend inappropriate wording. It is recommended that the activities programme is presented in a format that is suited to the needs of service users. DS0000013892.V302223.R01.S.doc Version 5.2 Page 28 Broadwater Lodge 3 OP16 It is good practice to make complaint record forms freely available to all who may wish to use them. It is recommended that the complaints which have been received are reviewed to ensure that any recurring issues can be addressed. Broadwater Lodge DS0000013892.V302223.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Surrey Area Office 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 DS0000013892.V302223.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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