Inspection on 20/04/05 for Broadway Lodge

This inspection was carried out on 20th April 2005.

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

The inspector 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 19/07/06

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 Mary Slattery Unannounced 20 April 2005 at 10:00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Broadway Lodge Address 151 Fulford Road, Fulford, York YO10 4HG 01904 621884 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Houssen Mohamud Baccus and Mrs Swabeeka Mohamud Baccus Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th January 2005. Brief Description of the Service: Broadway Lodge provides personal care and accommodation for up to 18 older people. The house 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, two sitting rooms and a dining room. The accommodation is over two floors and the first floor is reached either by a flight of stairs or a passenger lift. There are gardens to the front and back and parking space at the side of the house. There is ramped and level access around the home and to the garden areas. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 20th April 2005, which started at 10.00hrs and finished at 16.00hrs. A tour of the home was carried out which included the service users private accommodation, a selection of records were looked at and time was spent observing the activity in the home, talking and listening to service users and staff. The focus of the inspection was on a number of key standards, inspecting the care records of four service users in detail to establish if they corresponded with the service users experiences in the home. The proprietors were available throughout the inspection and the findings of the inspection were discussed with them What the service does well: What has improved since the last inspection? The manager has introduced a clear policy for the management of the home to ensure consistency in the day to day running of the service. There is a staff training programme and all new staff are inducted and have attended training on abuse awareness, health and safety and moving and handling. Medication training is planned to take place and NVQ training is ongoing. Areas in the home have been decorated, privacy locks have been fitted to all bathroom doors and hold open devices are to be fitted to some of the bedroom doors for those people who like to have their doors held open during the day. The training that staff have undertaken has improved their overall practice and heightened their awareness of adult protection issues. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1.3 and 5. People are provided with considered information about what the home provides. Information is gathered about people moving into the home to ensure that their needs are met in a safe manner. EVIDENCE: The statement of purpose and service user guide gave information about the home and the type of care and the services provided. The statement of purpose sets out the arrangements for service users and their representatives to visit the home before to making a decision to move in. Service users recently admitted to the home said that they visited the home and were given information that helped them make a decision to move in. One of the service users had been assisted by her family in making the decision to select Broadway Lodge, she said she was happy with this as her family lived near the home. The manager carries out a pre admission assessment and personal risk assessments prior to an admission being agreed. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 9 The assessment documentation of four service users recently admitted was inspected and contained sufficient information to form the basis of a care plan to ensure that their needs will be met. There was information about health and personal care, likes and dislikes, mobility and risk factors. The arrangements and wishes during illness and at the time of death. The care staff explained how they would meet the needs of the service users and how to minimise related risks. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. There are good systems in place to ensure that the service users health care needs are met. EVIDENCE: The service users care plans looked at gave information about their health, personal and social care needs and the arrangements that are in place for these to be met and by whom. The daily records showed what had been done and the outcomes of care delivered and any changes in their daily lives. Their health care needs had been identified initially at the assessment and through the process of care reviews. There was information about visits and treatments administered by doctors and district nurses and arrangements for keeping health care appointments. Some of the service users manage their own medication and written risk assessments were in place to safeguard them. They are provided with lockable facilities to keep medication safe. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 11 The service users looked well cared for, dressed smartly and said that the staff treated them with respect and that if they choose they spent private time in their own rooms. There were no arrangements in place for them to agree their plan of care or to sign their care plans. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15. Visiting arrangements are flexible allowing service users to maintain good and regular contact with family and friends. The meals provided are nutritious and offer a varied diet for service users but with limited choice of menu. EVIDENCE: The arrangements for visitors are detailed in the statement of purpose and on posters around the home. There is a sitting room available for service users to receive visitors in private if they choose not to use their own rooms. This is most useful where rooms are shared. The service users confirmed that visiting times were flexible and they could choose whom they wish to see. There were visitors in the home during the day of the inspection. People were relaxed and there was plenty of laughter. The service users said they enjoyed their food, they were offered a choice of menu and that there was sufficient quantity. Time was spent with service users over the lunch time period and the food appeared appetising well prepared and served in portions requested by the Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 13 service user. Staff were available to assist where necessary and lunch was a very relaxed affair. The lunch time menu was displayed and only showed one choice. The proprietor said that they are offered a choice of menu but that it is not displayed. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a relevant complaints procedure and staff’s awareness of abuse ensures that the service users are safeguarded. EVIDENCE: There is a satisfactory written complaints procedure and information about how to make a complaint is available around the home. All complaints made and the outcomes of any actions taken are recorded. The staff spoken to had recently attended abuse awareness training and had spent time reflecting on their practice. The service users spoken to said they felt safe and that they were able to discuss with the staff any aspect of the home and care that they were unhappy with and that changes are made to improve the overall service. There have been no recent complaints made against the home. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,24 and 26. The standard of the environment is good providing service users with a clean and homely place to live. EVIDENCE: The home was warm, clean and hygienic throughout and there are systems in place for infection control. There are systems in place to ensure that all equipment is tested on a regular basis and records to show that these checks have been carried out. The required safety certificates were in place including insurance cover. There is a programme of redecoration and maintenance and work completed includes: • The fitting of locks on bedroom doors. • Provision of a room for hairdressing. • Redecoration of communal areas. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 16 Work planned is to fit a new shower on the first floor and a sink in one of the ground floor toilets. The service users bedrooms were personalised and screening is in place in shared rooms for privacy. Equipment is available to assist service users with their mobility and adequate space around the home to accommodate service users who need wheelchairs. There is ramped and level access to and around the home and ramped access to the garden. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30. The service users receive a good standard of care from the staff a number of whom are working toward completing NVQ training. Failure to carryout the required checks on staff places services users at risk. EVIDENCE: The staff rota showed that the minimum numbers of staff are on duty both day and overnight night. Staff are employed to cook and clean but the care staff undertake these duties when the cook and the domestic are off duty. There is a staff training and development plan including NVQ training and staff are supervised on a regular basis. All new staff undertake formal induction training in relation to the needs of the service users and safe working practices. The required staff records were not in place. Application forms had been completed, one member had only one reference on file where two are required. POVA checks had been carried out and applications had been made to the Criminal Records Bureau. The staff had been employed prior to the CRB checks being completed. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33 and 38. The proprietor/manager has an understanding of the areas in which the home needs to improve. EVIDENCE: The manager of the home is working toward completing NVQ Level 4 in management. Information has been made available to inform staff and service users of the management arrangements for the home. This ensures that service users and the staff know who to refer to when the manager is away from the home. A number of new policies and procedures have been implemented to assist in the smooth running of the home and to provide evidence that work has been carried out. These policies refer to health and safety, moving and handling, safety of medication, risk assessments for service users who self medicate and staff induction training. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x 3 x 3 x x STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 3 x x x x 3 Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 29 Regulation 17 Schedule 2 Requirement The registered person is required to have two written references for all staff and a Criminal Records Bureau check prior to staff taking up thir post. Timescale for action 1st May 2005 and thereafter. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 7 15 30 31 Good Practice Recommendations It is recommended that arrangements are made for service users to agree and sign their care plans. It is recommended that choice of menu is recorded and displayed. It is recommended that 50 of the workforce are trained to NVQ Level 2. It is recommended that the manager completes NVQ Level 4 in management. Broadway Lodge J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 Page 21 Commission for Social Care Inspection 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 J53_J04_S15790_Broadway Lodge_V221594_200405_Stage4.doc Version 1.20 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. 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