Inspection on 10/07/07 for Broadway Lodge

This inspection was carried out on 10th July 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broadway Lodge 20/05/08

Broadway Lodge 19/07/06

Broadway Lodge 20/04/05

Broadway Lodge 20/01/05

Broadway Lodge 30/06/04

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

CARE HOMES FOR OLDER PEOPLE Broadway Lodge 151 Fulford Road Fulford York YO10 4HG Lead Inspector Donna Burnett Unannounced Inspection 10th July 2007 09:50a 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 Broadway Lodge DS0000015790.V343754.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. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadway Lodge Address 151 Fulford Road Fulford York YO10 4HG 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) 01904 621884 Mr Houssen Mohamud Baccus Mrs Swadeka Mohamud Baccus vacant post Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Old Age, not falling within any other category. Date of last inspection 19 July 2006 Brief Description of the Service: Broadway Lodge provides personal care and accommodation for up to 18 older people. The home is located in Fulford and is within easy reach of the local shops and on a main bus route to the centre of York. There are single and double bedrooms. The accommodation is over two floors and spread over two houses linked together by a corridor. The first floor is reached either by a flight of stairs or a passenger lift. There are pleasant gardens to the front and back and limited parking space at the side of the house. There is ramped and level access around the home and to the garden areas. The registered providers manage the day-to-day running of the home. Weekly fees currently range from £342 - £415 per week. This information was provided on 10 July 2007. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four hours were spent preparing for the inspection and gathering information about the service, including what had been happening at the home since the last inspection. A questionnaire asking for information about the home was sent to the providers before the visit and information from this was used to help plan the inspection. Surveys were sent to some of the relatives of people living in the home as well as a selection of health and social care professionals who have involvement with the service. Three relatives provided written comments. The inspection was unannounced and lasted six hours. All of the key standards were looked at to try and find out what it was like to live at the home. The registered providers were available throughout the inspection. A tour of the premises was carried out to see if the environment was being kept safe and pleasant for the people living in the home. The inspector spoke with several people living in the home and three visitors. Time was also spent speaking with staff on duty, looking at care plans and other records. What the service does well: What has improved since the last inspection? Refurbishment and improvements have been carried out to the home. This makes it a safer, more pleasant place in which to live. Controlled medication is counted and the stock balance checked so that the chances of errors occurring are minimised. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 6 People living in the home use their own toiletries. This reduces the risk of cross infection from one person to another. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. People who use the service experience good quality outcomes in this area. People new to the home are assessed before they move in and a package of care planned for so that care needs can be met. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: A needs assessment is carried out for every person thinking about coming to live at the home. This is so that their care package can be planned and prepared for. People are invited to come and look round the home beforehand to see if they think they would like it. A review is carried out within the first few weeks of moving into the home. This provides an opportunity to see how people are settling in. The home provides leaflets and written information so that people can know what to expect from the service. The home does not provide an intermediate care service so this standard was not looked at. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. People are treated with respect and get the support and help that they need. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Individual plans of care provide care staff with information about what help and support to give to meet people’s needs. The plans are reviewed regularly so that the information on them is kept up to date. However, one of the plans which was looked at did not identify one person’s risk of choking or say how to minimise the risk. Although steps had been taken to reduce and monitor the risk, it had not been recorded. There is a chance that new care staff would not be aware of the risk or know what to do to minimise it due to the lack of written information. In accordance with The Care Home Regulations 2001, there should be certain information in respect of each person living in the home. A photograph should Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 10 be obtained for each person so that they can be easily identifiable, especially for new or agency staff. People who live in the home have access to a variety of health and social care professionals, which ensures that they get the help and support they are entitled to. They can choose which GP they want to be registered with. Specialist equipment is made available for people assessed as needing it. Risk assessments are carried out to show the safest way to support and care for someone. Medication is administered using a safe, recognised system, which minimises the chances of mistakes happening. An audit carried out by Boots, who supply medication to the home, found the storage, administration and record keeping of medication in the home to be ‘above the required standard’. People were observed being spoken to kindly. People living in the home describe the care staff as ‘very polite’, ‘respectful’ and say that their manners as ‘impeccable’. Relatives say that they have ‘no concerns about care’ and that there is ‘far more’ care than they ever thought they would be able to get. There are two shared bedrooms which each accommodates two people. Screening is provided so that personal care can be provided in private. People choose whether or not to share a room. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience good quality outcomes in this area. People living in the home are supported to keep in contact with their families and friends. They enjoy good, nutritious food. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home does not employ a designated activities organiser and the amount of time that the care staff spend engaging in recreational activities with people living in the home is limited. One relative commented that their family member sometimes gets ‘bored’ and would benefit from a ‘change of scenery and a bit more fresh air’. However, people spoken with were generally happy to spend their time reading, listening to the radio or watching television. Visitors are made welcome and can be seen in private. People who wish to keep in closer contact with friends and relatives can have their own telephone. A relative who returned a survey said that the home is good at keeping them informed and that they receive regular telephone calls to tell them ‘of any changes or forthcoming changes’. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 12 From time to time school children or singers will be invited to provide entertainment. People living in the home recently enjoyed a visit from the mayor in celebration of a special birthday. People are encouraged to bring possessions into the home and many of the rooms are very personalised. This makes the rooms comfortable and homely for people who choose to spend much of their time in them. One relative who returned a survey spoke of how their family member ‘enjoys being consulted with regarding the soft furnishings of the home’ and how their ‘opinion is still valued’. People who live in the home are able to express choice and control over their lives and are not bound by routine. For example, if someone doesn’t want to have a bath one day they can ask to wait until the next day. People who live in the home speak highly of the cook who has worked at the home for several years and has a good knowledge of people’s likes, dislikes and dietary needs. People can choose to eat in their rooms if they wish. Assistance and supervision is given to people who need it. The kitchen is clean, well organised and subject to routine environmental health inspections, which makes sure it is a safe place in which to store and prepare food. However, some of the food in the freezer was not labelled. Although the cook was able to say what the food was and when it had been put there, it would not have been clear to anyone else. This potentially puts people at risk of eating food which is out of date and not safe to eat. The menu is varied, the food wholesome, and there is always an alternative. People living in the home enjoy the home baking and benefit from food which is nearly all freshly prepared. The food budget is not restrictive. Some of the people living in the home help with the shopping, much of which is done locally. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. People know who to go to if they have any concerns although not everyone is comfortable doing so. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home’s complaints policy is on display in the entrance so that anyone wishing to make a complaint can know how to go about it. A record is kept of all complaints made and shows what happens to address any issues raised. The providers are in the home a lot and make an effort to speak to people living in the home, family members and staff, about any concerns that they might have. Despite all of this, some people who were consulted with do not feel comfortable speaking out about any complaints or concerns that they might have. They feel that ‘saying nothing is better than complaining’. Others however said that it wasn’t a problem and felt able to speak out. This was discussed with the providers at the end of the inspection. They plan to arrange for people living in the home, their relatives and members of staff, to have greater opportunity to make suggestions about changes or improvements that they would like to see. Care staff are trained to look for and report behaviour that could harm people living in the home. There are a number of policies and procedures in place Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 14 which address aggression, harassment and bullying so that the people who live and work in the home are safeguarded from abuse. The providers have previously dismissed a member of staff whose work practices were not satisfactory. This shows a commitment to the protection of the people living in the home. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. The home is a safe, comfortable place in which to live. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home and gardens are well maintained and safe for the people living in the home. Records show that ongoing maintenance and repairs are carried out. The choice of furnishings and décor provide a homely environment. A relative who returned a survey describes the home as ‘warm and comfortable’. There is enough communal space for people not to have to spend time in their bedroom unless they particularly want to. Domestic staff keep the home clean, tidy and free from unpleasant smells. People’s clothes are well looked after and kept in a good state of repair so that dignity is preserved and appearance maintained. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience good quality outcomes in this area. They are cared for by members of staff who are kind and caring. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Staffing levels are sufficient to be able to meet the needs of the people living in the home. Domestic and catering staff are employed so that care staff can concentrate on the personal care needs of the people living in the home. People say that they do not have to wait long if they need help. Care staff are suitably trained and over half of them have achieved a recognised qualification in care. This makes for a competent workforce. Police checks are carried out and references are obtained to check on the suitability of potential employees. It could not be evidenced however that the identity of the applicants had been verified. Photographs and copies of passports and birth certificates should be obtained so that the identities of people employed to work at the home can be confirmed. A sample of training records were looked at and showed that new staff receive induction training to know how to look after people properly. Care staff are trained in fire safety, first aid and infection control and attend courses relevant to the care of older people. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 17 People living in the home describe the care staff as ‘very good’, ‘wonderful’ and ‘very caring’. They say that ‘nothing is too much trouble’ for them. Some concern was expressed however about communication difficulties. Many of the care staff are from overseas and have strong accents, which some people living in the home struggle to understand. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. People who use the service experience good quality outcomes in this area. Their health, safety and welfare is protected. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home is managed by the registered providers, Mr & Mrs Baccus. Mrs Baccus has obtained a qualification in care to support her in the day to day running of the home. They are usually in the home during the week and make themselves available for people to speak to. They can also be contacted out of hours and during the weekends. A relative who returned a survey commented that telephone calls are returned quickly should the manager be initially unavailable. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 19 The providers try and seek the views of people who use the service, and their families, but in a very informal way that can not be evidenced. Some people are reluctant to express their views and the providers could look more closely at the way in which they monitor the quality of the service. The majority of people living in the home are assisted by their relatives to look after their money. There is one person whose personal allowance is looked after by the providers. The records looked at were not easy to follow, not clearly documented and did not tally. This was discussed with the providers who agreed to keep better records of all financial transactions undertaken so that all money can be accounted for and mistakes avoided. The providers ensure the safety and well being of people living in the home by making sure that essential health and safety checks are carried out, ensuring that equipment is safe to use, and by training staff to work safely. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 X X 3 Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17(1)(3) Schedule 3 Requirement Records referring to people living in the home must be kept up to date, accurate and include a photograph. This will ensure that care staff clearly know the care and support they are to give to each person living in the home. Food that has been removed from its original packaging must be labelled and dated. People living in the home need to feel confident that what they are eating is suitable and in date. More formal arrangements should be put in place for people who live in the home, and their representatives, to be consulted with about the quality of the service. Clear, accurate records must be kept of money handed over for safekeeping. All financial transactions undertaken on behalf of anyone living in the home must be documented so DS0000015790.V343754.R01.S.doc Timescale for action 10/09/07 2. OP15 13 11/07/07 3. OP33 24 10/10/07 4. OP35 17(2) Schedule 4(9) 10/08/07 Broadway Lodge Version 5.2 Page 22 that peoples interests are safeguarded. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP29 Good Practice Recommendations For people working at the home it is recommended that photographs and copies of birth certificates and passports are obtained, and kept on file, so that their identities can be verified. Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broadway Lodge DS0000015790.V343754.R01.S.doc Version 5.2 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. 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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