Inspection on 19/07/06 for Broadway Lodge

This inspection was carried out on 19th July 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 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 10/07/07

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 Ms Anne-Marie Foster Key Unannounced Inspection 19th July 2006 09:00 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.V305109.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.V305109.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 MohamudBuccus Mrs Swabeka MohamudBuccus Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 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 spread over two houses linked together by a corridor and over two floors, 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 are £332.00 – this information was given on 6th June 2006 Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place on 19th July and took six hours; the registered providers Mr and Mrs MohamudBuccus were available to assist the inspector. Twelve service users and four relatives were spoken with during the site visit, and also service user surveys were handed out in order to gather further information about the home. The care files of 6 service users were looked at, as were 5 staff files. All of the staff on duty were spoken with and discussions were held with the registered providers. The home sent a pre-inspection questionnaire in to the inspector, providing more information about staff rotas, menu samples and fees. The inspector made observations of the staff on the day during their interactions with the service users. A tour of the home was made including service users rooms and communal areas. What the service does well: What has improved since the last inspection? The recruitment procedure for staff at the home is now robust, with the relevant pre employment checks in place before allowing a new recruit to start work, this will help to safe guard the service users from the employment of unsuitable people. The registered provider responsible for the management of the home has now obtained her NVQ4 certificate in care and found that the information she gathered during these studies was very useful, this will contribute to the effective management of the home. The menu displayed now shows what alternatives are on offer, enabling the service user and their families to make informed choices. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 6 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 DS0000015790.V305109.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.V305109.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. No service user moves in to the home without being assessed, so that the home can be sure they can meet the needs of the individual. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides good information in their service user guide and statement of purpose; this will help prospective service users to make an informed choice about where to live. The registered providers go out to assess any prospective service users, so that they can understand the needs of the individual and be sure that the home can meet them before accepting for admission. Broadway Lodge DS0000015790.V305109.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 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 good. The health, personal and social care needs of the service users are met, however improvements need to be made to the medication system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of six service users were inspected and the care plans were found to be comprehensive and individualised, this will support the staff and enable them to deliver the appropriate care. There was not a clear page in the care plans for the review information, making the review date hard to find; a separate page for this and any comments should be added, so that it is clear that the care plans have been reviewed and are up to date. Twelve service users were spoken with on the day of the site visit, and those that were able to comment were positive about life in the home and said “we have everything we want” “ staff are very kind and friendly”” staff try very hard to get it right” and so they could demonstrate that their needs were being met. Service users looked well, they were smartly dressed, the ladies had their hair styled, wore their jewellery and had manicures, the men were smart and clean shaven. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 10 The home was well organised in facilitating health care appointments, one person had the GP attending, and another was being taken to see the G.P. plus one lady was about to attend the district hospital for a consultation, the arrangements had been set in place to ensure the service users health is promoted and that they continue to be able to access health care services outside of the home. The homes medication system was inspected, a monitored dosage system is used and the providers and senior carers administer the medications ;on inspecting the controlled drugs stock it was noted that a balance of the remaining stock is not recorded in the book, as is recommended by the Royal Pharmaceutical Society - that the balance of controlled drugs be checked at each administration and also on a regular basis e.g. monthly, so as to prevent or detect early, any administration error. Whilst inspecting one of the bathrooms it was noted that a large amount of toiletries were stored on a cupboard communal toiletries are not to be used as this might pose a compromise to the service users dignity and could potentially cause a risk of cross infection. Staff were observed during their care duties, and were seen to work in a calm quiet respectful way, addressing the service users appropriately, and so maintaining their respect and upholding their right to privacy. Broadway Lodge DS0000015790.V305109.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 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. Service users live in a home that matches their expectations and they are helped to exercise choice and control in their life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The lifestyle at the home is flexible, one service user was allowed to have a lie in as she didn’t want to get out of bed until lunchtime, meaning that the service users are able to exercise choice in their routines of daily living. Visitors are able to come and go in the home as the service user pleases and the home provides a pleasant visitors room should the service user wish to use it, there were several relatives visiting on the day of the inspection including the local vicar who had come to administer communion, demonstrating that community contact is developed and maintained according to the individuals wishes. The homes menus and lunchtime meal were observed, the lunch which was roast chicken followed by fruit jelly and ice cream this was thoroughly enjoyed and everyone made positive comments “ it was delicious” “ it was just right for a hot day” demonstrating that service users receive a wholesome appealing balanced diet. The lunch is served in the two dining room which are laid out in a pleasant way, the cook is flexible with her menu and can change the meal at Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 12 short notice e.g. to a salad on a hot day if the service users make a request and she is particular in paying attention to their likes and needs meaning that an appealing menu is developed. The mealtime was served in an hurried fashion and staff were seen quietly assisting as necessary and so service users had time to eat well. Broadway Lodge DS0000015790.V305109.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 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. Service users are protected by a clear complaints policy and feel confident that any complaint they have will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints policy, and service users and staff said they would know how to make a complaint, that they would be taken seriously, and could be sure that their complaint would be acted upon. The complaints book was inspected and the five complaints that were recorded had all been investigated and an outcome reached, this demonstrated that the home follows its own complaints procedure and that service users feel confident and able to make a complaint. The home has clear policies to safeguard the service users. The providers are responsible for managing some of the service users monies and have clear written policies relating to this, and so are able to support the service users and facilitate their access to personal finances. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users live in a clean safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is accessible, clean and hygienic, the providers are on site every weekday and arrange any maintenance work using local contractors. In some areas of the home the décor is looking dated, particularly the lounges and dining areas, the providers do have a redecoration programme in place though, so they can continue to provide a comfortable and congenial setting. The garden at the front of the home is well kept and service users were able to sit out in the shade of mature trees, which service users said was “pleasant and enjoyable” The home is free from offensive odours and the domestic takes pride in her cleaning work, the laundry facilities are well sited and satisfactory and the specialist washing machines perform well, and so the service users are safe guarded from any risk of cross infection. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. Service users needs are met by a welltrained group of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rota shows that the minimum amount of staff are employed overnight, with one waking carer on duty and one sleeping in but ‘on call’, the night carer was spoken to and she did confirm that nights were quiet and that the service users needed little care during the night, the providers live just across the road from the home and are happy to be called out at any time, six service users spoken to reported that nights were quiet with no problems, and so the home can meet the needs of the service users during the night. Each member of staff on duty during the day said that there was enough staff to meet the needs of the service users. There are now over 50 of staff with NVQ2 certificate in care, and also two of the senior carers are registered nurses in the Philippines and so are experienced in providing care duties, which ensures that a good skill mix is provided to meet the needs of the service users. The home has a good recruitment system based on equal opportunities, new employees have the required criminal record bureau checks, a clear employment history and two good written references before they are allowed to start work; six staff folders were inspected and the documentation required by regulation was found to be satisfactory - this good practice ensures the protection of the service users. The home provides many opportunities to attend in house and external training and all staff receive the mandatory Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 16 induction training and foundation training. The staff files were inspected and the training certificates were found to be valid and up to date, other training that is not mandatory is arranged for staff for example dementia training, and ‘depression in the older person’, meaning that staff are well trained and competent to do their jobs. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. Experienced managers, who have the service users best interests in mind, run the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has now obtained her NVQ4 certificate in care and reports that the course was very useful in relation to day to day operations of the home, this means that the manager is further qualified to run the home and meet its stated purpose, aims and objectives. The home provides an annual satisfaction survey to the service users, in order to seek their views, and relatives have good access to the providers in order to be able to express their opinions, enabling the home to be run in the best interests of the service users. The providers are responsible for the management of some of the service users monies, written receipts are kept for all transactions and the home has a safe to keep money and valuables in, meaning that service users financial interests Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 18 are safeguarded. The home has clear policies relating to health and safety and staff are trained in health and safety matters including moving and handling, fire safety, first aid food hygiene and infection control. Documents were inspected and found to be satisfactory with regard to boiler servicing, electrical equipment testing, water temperatures, as were staff training certificates ensuring that the health safety and welfare of service users and staff are promoted and protected. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 19 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 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 20 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 OP9 Regulation 13(2) Requirement The registered manager should ensure that the controlled drugs policy of the home is in keeping with the Misuse of Drug act 1971 and record a running total of controlled drugs after each administration. Timescale for action 31/07/06 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 OP7 OP10 Good Practice Recommendations It is recommended that the care plan review date is set out clearly in the records, and that there is space to write down any changes to the plan It is recommended that service users have their own toiletries and do not share communal toiletries. Broadway Lodge DS0000015790.V305109.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000015790.V305109.R01.S.doc Version 5.2 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!