Inspection on 14/02/06 for Broadway Lodge

This inspection was carried out on 14th February 2006.

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 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 07/11/07

Broadway Lodge 20/03/07

Broadway Lodge 05/12/06

Broadway Lodge 22/08/05

Broadway Lodge 15/02/05

Broadway Lodge 05/08/04

Broadway Lodge 08/03/04

Broadway Lodge 10/02/04

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

CARE HOME ADULTS 18-65 Broadway Lodge Totterdown Lane, Off Oldmixon Road Weston Super Mare North Somerset BS24 9NN Lead Inspector Nicola Hill Announced Inspection 14 & 15 February 2006 09:00 th th Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 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 DS0000020317.V273506.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 DS0000020317.V273506.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Broadway Lodge Address Totterdown Lane, Off Oldmixon Road Weston Super Mare North Somerset BS24 9NN 01934 812319 01934 815381 paulinebissett@broadwaylodge.org.uk 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) Broadway Lodge Limited Mrs Pauline Bissett Care Home 55 Category(ies) of Past or present alcohol dependence (55), Past or registration, with number present drug dependence (55) of places Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 33 Primary Care and up to 22 Secondary Care persons with alcohol and drug dependency, eating disorder or codependency. Staffing Notice dated 15/12/2000 applies. Manager must be a RN on part 1 or 12 of the NMC register. Broadway Lodge may accommodate up to two residents who are over 65 for the rehabilitation programme. 22nd August 2005 Date of last inspection Brief Description of the Service: Broadway Lodge is a charity set up to provide treatment for individuals suffering from alcoholism, chemical dependency, eating disorders and co dependency. The home provides detoxification services, and residential primary and secondary care within the framework of the 12 Step Recovery Programme. The residential primary care is sited in the main building and is also able to offer nursing care support. The residential secondary care is within a domestic type house and bungalows situated within the grounds of the property. The mission statement for the home is” To provide the highest quality treatment for people suffering from alcoholism, chemical dependency, eating disorders or codependency. To treat everyone with respect, taking into account individual needs, offering hope and freedom.” Broadway Lodge is situated on the outskirts of Weston-super-Mare, and can be easily accessed by public transport. There are nearby shops which residents are able to visit, and residents can use the local primary care health centre services. The home has established strong links with the local AA and NA groups that residents attend at appropriate times in the programme. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at Broadway Lodge was undertaken over two days, and included the primary and secondary units. The inspector gathered evidence from residents, staff, and documentation held at the home. The inspector also observed the stress management group, the house meeting for primary care residents and attended the morning feedback meeting. The inspector took lunch with the residents in the secondary care units, and had the opportunity to talk to both groups about their experiences of the programme at Broadway Lodge. At the time of the visit to Broadway Lodge, the primary care group were going through a period of instability. This was evident in the behaviour displayed by the residents towards each other, and towards their environment. The staff team addressed this with the residents within the house meeting, and will be closely monitoring the situation. This was discussed in depth with the registered manager, and the nurse manager. The team brief for the following day will focus on introducing measures, which will refocus the residents onto the programme, and reiterate the residents individual responsibilities and expectations. The staff team are well established and secure in their knowledge of the client group and patterns of behaviour exhibited as people move through the programme. Broadway Lodge has successfully achieved accreditation with European Association for the Treatment of Addiction (EATA). The board assessing the accreditation application stated that Broadway Lodge presents and number of positive features that seem particularly appropriate for a rehabilitation service. Among these are the use of many groups to address specific issues or problems; the integration of support systems both within and outside the form of treatment regime; the use of social events and activities to support service users in recovery to develop social networks. The accreditation is valid for three years. What the service does well: Broadway Lodge provides a robust treatment programme for those addicted to drugs or alcohol or with eating disorders. Within the primary care there are currently a range of these issues to address. The residents there are supported by the staff team, and the quality of support from the nurses and counsellors was noted by residents and appreciated. The accommodation, whilst communal, is of good quality and there are a variety of facilities available for personal care. The home is well maintained, and the handyman deals with any issues requiring attention. The primary care residents are enabled within the house meetings to raise any concerns and speak directly to staff or other residents in order to find a resolution. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 6 The five houses that make up the secondary care units are sited in a residential street and are maintained to blend with the local environment. The residents were very positive about the care and support received whilst at Broadway Lodge. The residents stated that programme allowed flexibility with very clear boundaries, and the group therapy supported the continuation of the key themes of the programme in the absence of staff. The residents in secondary care also take on additional responsibilities; this was felt to be a very good opportunity for them to test their coping skills and to be able to assert themselves in a challenging environment. The home has a good reputation locally and nationally, and can deal effectively with people with multiple addictions. Everyone wishing to attend the programme at Broadway Lodge is assessed individually in relation to the support that the home can provide, or access. The team responsible for admissions to the home are efficient, and process applications quickly. The home also has good relationships with commissioning teams. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Broadway Lodge has a robust admissions process. The admissions department have the initial contact with people wishing to move into Broadway Lodge, and have a good knowledge base about the opportunities the programme offers people to rehabilitate from addiction. EVIDENCE: The registered manager keeps the statement of purpose and service user guide under yearly review. This is to ensure that the staffing information is up-to-date, and that the information gathered from exit questionnaires is included and reflects the views of people who have used the service. The admissions department have the initial contact with people wishing to move into Broadway Lodge, and have a good knowledge base about the opportunities the programme offers people to rehabilitate from addiction. All the residents have an assessment undertaken prior to admission, which covers all aspects of their life including any mental health issues. It is from this information that a decision is made to offer a place on the programme. The team, in relation to the needs of the whole group, considers the individual needs and it may be appropriate to defer an individuals admission until the group needs have changed and the individuals needs can be addressed. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 9 The residents currently in Broadway Lodge were able to tell the inspector that they had a choice of home to go to, however Broadway Lodge was chosen either because of the personal recommendation, either from care managers or from people who had already been through the programme. One resident spoke about the service user guide, and was aware of the purpose of it. Other residents agreed that they have received file with information it, and had used other methods to answer their queries such as their buddy, or the staff team. The residents also demonstrated an awareness of the funding issues, and that an individual contract for them between the service commissioner and Broadway Lodge existed. The individual contracts for residents who are on licence from prison or have DTTOs were available to the inspector. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6-10 The programme recognises and supports individual needs through individual and group therapy. EVIDENCE: All of the residents have an individual care file. The residents had their individual needs reflected on the care plans, and there was evidence that plans were reviewed and evaluated on a regular basis. The home also maintains a daily record on each resident which is a reflection of the daily life of resident was going through the programme of rehabilitation. In addition to this the counsellors keep records of therapy sessions. The residents also record significant events on a daily basis. The home also records any visits to other agencies such as GP, probation officer. The care documentation at the home links together and can be used to track a residents progress from the initial referral with the presenting care needs to working through the programme, and the after care required on discharge e.g. housing. This presents a picture of caring for the whole person rather than just dealing with the recovery from addiction. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 11 Individual choice and decision making is subject to the limitations of the programme, however, all the residents stated they were treated as individuals and supported as such. The residents in primary care currently have a very different view of the programme than those in secondary care. The strict routine and house rules do require a period of adjustment, which varies with the individual. However, some of residents in primary care demonstrated that they lacked the understanding of the need to have the same regime for all service users. The inspector was asked about residents being able to have a gym room and particularly use weights in order that they could relieve stress. There was also a request to the inspector that music be piped throughout the home, as this would help relieve the boredom. Primary care is only for eight weeks, and the inspector explained that whilst the organisation seek service users views and suggestions to improve the service, the treatment programme and responsibilities of service users in the programme will not change. The house rules and regime have been successful for many residents and cannot be changed to accommodate individual preferences. Within the home there are personal choices made about meals etc, and all residents can leave the programme if they wish to. With the secondary care service users the predominant view was that they understood the house rules were for their own good, and that it enabled them to focus on their progress through the programme. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11-17 The programme has clear boundaries, which support personal development and independence. EVIDENCE: As part of the programme the residents attend AA and NA meetings. The home operates a programme of group therapy and group support so that the residents learn to deal with issues that arise for them and to support others. The secondary care resident group at Broadway Lodge stated that they had learnt about themselves, especially through doing their life story, and by receiving feedback from their peers. The group support also ensures that people cannot isolate themselves when there are no planned therapy groups, and that untoward behaviour is challenged. The residents felt that on their arrival to the home this felt quite strange, however the benefits of having a peer group often more advanced in the programme than themselves was very positive and allowed them to express ideas/concerns as they occurred rather than having to wait until there were counsellors available. The residents were Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 13 also very aware that the programme at Broadway Lodge although quite intensive had a high success rate. Within the group there is also a responsibility toward others, and one resident commented that they felt safe within the group and that what was discussed in sessions was confidential and not taken to outside agencies. The primary care resident group currently have issues of respect and responsibility. This is being addressed with the support of the staff team. The home continues to offer support to families with relatives who are in the programme. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18-20 The home has demonstrated a holistic approach in promoting good health and well being of its residents. EVIDENCE: None of the residents currently at Broadway Lodge requires support with personal care; currently there is one service user in primary care that is a wheelchair user and has been successfully accommodated. All the residents require support through the programme, which is provided through counselling on a one-to-one basis and through group therapy. The house rules dictate that residents are well groomed and wear clean clothing in order to develop their personal-care skills and their sense of respect of themselves and towards their peers. Some of the residents have health care needs which require external appointments such as hospital treatment, these needs are assessed on admission and local services accessed when necessary. The service users our supporters to achieve optimum health and well being, the home provides within the programme additional groups such as stress management, in order to support good health. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 15 The residents are assessed in secondary care toward the end of the programme for there ability to self medicate. However the prescribed medication is stock controlled, and recorded by the staff. The nurse manager and the inspector were able to review and audit medication stored at home. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 The complaints procedure is available to all residents. EVIDENCE: There have been no complaints recorded at Broadway Lodge, and though complaints received by the Commission about the home. The manager and inspector discussed the intention of a resident in secondary care to make a complaint. This was not unexpected, as the resident had threatened ever since arriving to make a formal complaint but had not yet done so. When reviewing the daily records, the inspector read an entry that related to the residents intention to complain. The resident was given the complaints procedure, and has been given the contact details for the Commission should they choose to complain. The usual route for raising issues of concern would be that residents raise them either directly with staff or through the regular house meetings. It was noted that the primary care residents at their house meeting, at which the inspector was an observer, raised the same issues they had spoken to the inspector about. The concerns discussed at the meeting focused on the individual behaviours of residents whilst living as a community, and the lack of respect shown to their environment and each other. The group also appeared to be under the impression that the programme and the house rules should be flexible to suit the most vocal of the resident group. The inspector is confident that the staff will exercise their knowledge and experience to control the situation and reiterate the purpose of the programme and the expectations and responsibilities of the residents following the programme. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 Broadway Lodge is well maintained and provides suitable facilities for its target client group. EVIDENCE: The inspector toured the primary care building with the registered manager and the nurse manager. The home is in a good state of repair with adequate funds allocated for maintenance. The grounds are extensive and well maintained. The accommodation for the residents is comfortable and efforts have been made to ensure that bedroom furniture matches and that each resident has sufficient room. The bedrooms are shared, but were very clean and tidy. There are sufficient bathrooms and toilets, with a wheelchair accessible shower room on the ground floor. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 18 Broadway Lodge employs ancillary staff for cleaning the home that does a very thorough job, the residents also support maintaining the homes’ cleanliness through therapeutic duties. It was noted that one bed has cot sides and the nurse manager was advised to produce a protocol for their use, which takes into account the latest guidance on correct positioning, and use of padded protection. Broadway Lodge is a pleasant and well maintained environment with a variety of communal areas available to residents. The coffee lounge is the only area where smoking is permitted, however in order to open this facility to non smokers, the use of the premises is being reviewed in order to identify a suitable smoking area. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 The staff team are well trained and highly experienced in providing rehabilitation programme. EVIDENCE: The manager was able to provide the inspector with a staff rota, which demonstrated that there are sufficient staff, nursing, counselling and ancillary, to maintain the support for residents over a 24-hour basis. The manager also provided individual staff records of training; the courses attended by staff were role specific and enhanced the skill mix and experience of the staff team. The residents were extremely positive about the support received from the staff team; one resident who had been admitted to hospital was astounded at the support given during the hospital stay, especially as they were visited by their counsellor or another member of staff are regular basis. The residents were also impressed at the experience of the staff team, and their knowledge of addiction and the rehabilitation processes. The staff are supported in various ways, the most important being the strong team identity and support given through meetings such as the morning Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 20 significant events discussion, and feedback sessions after therapy groups. The staff receive individual supervision for personal development and training, supervision is given by an outside agency for counsellors, and individual staff groups have staff meetings. The manager and the inspector discussed the placement of counsellor and social work students at Broadway Lodge. There are records available relating to the students on placement, which include an enhanced CRB check. All students are interviewed prior to the placement, for suitability, and the staff team use this as a selection process. References for students are not kept on premises, but are available from placing colleges/organisations should they be required. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37-43 The established management systems are open and flexible to support the changing need the client group. EVIDENCE: The current registered manager for the home, Pauline Bissett, has been in post for eight years, and has attended training to update her skills and to maintain her registration with NMC. Mrs Bissett is due to retire at the end of the year with, and is currently working with a mentor to manage the process of recruiting a new chief executive. The manager has combined roles and has retained oversight of clinical as well as business matters. The manager has retained contact with the client group, and also works very closely with the staff team attending regular debrief meetings, as well as organising the staff meetings and supervision. The residents know the Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 22 manager by first name, and are not hesitant in approaching her with any concern or problem. The quality monitoring at Broadway Lodge is undertaken in several ways, including the exit questionnaire completed by service users when leaving the programme. The home also notifies NTA of all admissions and discharges. The outcomes of the questionnaires completed by ex-service users are used to form the basis of business planning for the home. The processes used for monitoring quality are the daily auditing for health and safety etc., completion rates, accident monitoring, staff turnover and sickness monitoring, budget management, referral and admission rates. The home has also been accredited by EATA and has a high profile both locally and nationally. The homes policies and procedures are reviewed on an annual basis and reflect current legislation and good practice guidance for rehabilitation programmes. The record-keeping at the home is maintained by the staff; residents are aware that they have the right to see all records held on them, currently the home is perfecting their computer system to allow for computer records to be accessed and maintained by staff electronically. All of the computer records are protected by passwords. The inspector was able to see records of testing and maintenance of equipment such as boilers lifts. The portable appliance testing records were up-to-date. The fire alarm system testing had been implemented appropriately, with regular testing of equipment. The inspector reviewed the accident records for residents/staff, which indicated several minor incidents, which were not predictable and therefore not preventable. Whilst touring the building there were no areas of concern about the health and safety implementation in either primary or secondary care. Broadway Lodge is run as a charity and has a board of trustees who are accountable to the Charity Commission and ensure that the financial accounting meets the Charity Commission guidance. The financial accounts for 2005 were available to inspector and indicated that Broadway Lodge is financially viable. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 3 3 3 Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 24 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. Standard Regulation Requirement Timescale for action 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 YA29 Good Practice Recommendations The nurse manager produce a protocol for the safe use of bed rails. Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Broadway Lodge DS0000020317.V273506.R01.S.doc Version 5.1 Page 26 - 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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