Inspection on 20/03/07 for Broadway Lodge

This inspection was carried out on 20th March 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broadway Lodge 07/11/07

Broadway Lodge 05/12/06

Broadway Lodge 14/02/06

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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Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

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 Unannounced Key Inspection 20 & 21st March 2007 09:30 th Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 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.V332550.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 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.V332550.R01.S.doc Version 5.2 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 TBA 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.V332550.R01.S.doc Version 5.2 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. 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 codependency. 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 co-dependency. 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, which residents attend at appropriate times in the programme. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of the home took place with the inspector and the acting manager Stephanie Noble. The inspection took place over two days and involved a review of documentation, a brief tour of communal areas and discussion with residents currently at the home. Broadway Lodge is a well established treatment centre and has always been involved in researching and implementing new practise within the field of addiction. Currently the home has an acting Chief Executive, Brian Dudley, and an acting manager, who between them are providing the management and leadership in the home following the demise of the Chief Executive, Graham Menzies, appointed in late 2006. This is an interim arrangement for up to six months to allow the board time to recruit an appropriately experienced person to the service. The home was inspected against the minimum standards and it was found that two specific areas of the practise at the home had failed to meet the required standard. This precipitated an immediate requirement being made in respect of standards 6 and 14, regulations 14, 15, and 17. This has affected the quality level for the service, which has assessed as providing an adequate level of service. What the service does well: The residents who spoke with the inspector praised the level of support provided by all members of the staff team at Broadway Lodge, including the domestic team and clinical team members. It was stated by one resident that the home went the extra mile to ensure that the treatment programme was tailored to meet individual needs and ensure a continuity of care between the home and external authorities. The home is pleasantly decorated and furnished to ensure that it is comfortable and not institutional; the ancillary staff are regarded highly by residents for the provision of nourishing meals and their maintenance of the home. The organisation continue with their good practise in that each resident is regarded as an individual, with individual clinical needs which the team discuss and plan the most appropriate interventions and identify the most skilled member of the team to meet the need. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The organisation has instituted a computer system for patient records that has removed the use of paper documentation from the home. In doing so they have failed to recognise that the system is not configured to provide an individual care plan for residents which meets the National Treatment Agency service specification for care planning and the requirements of the National Minimum Standards for Younger Adults. The consequence of this was that at the time of the inspection none of the 44 residents currently in treatment at the home had a plan of care which documented how individual needs were met; this also impacted on the appropriateness and effectiveness of any interventions initiated for the residents and also where a risk assessment identified a potential problem there was no evidence of control measures being put in place to reduce the potential risks to residents and staff. An immediate requirement was issued in respect of this service failure and the home will be revisited to ensure compliance. The home has also failed to respond to verbal requests that the accountability and responsibilities for areas of service function were clearly identified and recorded so that the division of responsibility between the acting manager and acting chief executive are known and understood by internal staff and external agencies. Areas of improvement outstanding from the last inspection are the disciplinary discharge process and analysis of why it happened. The management must be proactive and respond appropriately to significant events. The home also need to develop their marketing system by producing easily read information about the service, and develop direct relationships with service commissioners. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 7 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 DS0000020317.V332550.R01.S.doc Version 5.2 Page 8 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.V332550.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents have a high opinion of the process of admission to eh home which responded to individual need. EVIDENCE: The home has a detailed Statement of Purpose, which is available to all potential residents and reflects the current management structure. It provides details of the homes philosophy, therapeutic programme, facilities and timetable of activities. The inspector and acting manager discussed how to present the information in a simplified way, with emphasis on a person centered programme, but which also captures the views and enthusiasm of residents who have been through the programme. All of the documentation is being reviewed to reflect the new corporate image of the organization, which residents confirmed that they had been consulted about. It is planned to update the video information to a DVD format which will be produced by ex residents who have been successful in their recovery. There may also be scope for ex residents to be proactive in the marketing of the home to service commissioners. The admission process for Broadway Lodge was discussed with the acting manager and the residents. The merits of a telephone referral process and the preadmission visit were discussed; the inspector suggested to the manager that the admission type and completion rate could be compared to give an Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 10 indication of what was most successful for residents. The obvious deficit in the current admission process is that for perceived straight forward admissions there is no input from the nurse/medical team. As the acting manager must take responsibility for admissions and agree that the home can meet identified need, then involvement in the process should be actioned. The admission process for people with a difficult history or dual diagnosis is that they must have a preadmission assessment at the home and this practice will continue. For the residents the admission process was good in that they immediately felt that staff treated them as individuals not just as an addict or an alcoholic. The process felt safe to them and although it was a difficult transition to make the residents stated that they were thoroughly supported through it; the immediate support on arrival from the nurses’ team and introduction to a buddy was reassuring as was the access to counseling support on a daily basis for the first week. In summary the outcome of the admissions process for residents was felt to be excellent and exceeded their expectations. At the time of the inspection there were 44 residents, male and female, age group 18-64 years; none of the residents had any diagnosed disability. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people using the service do not have a care plan and the computer system used for residents records is poorly developed and fails to provide the correct links between information. EVIDENCE: At the time of the last inspection the records were in paper form and computerised, the plan was that all records will be held on the computer and are therefore accessible to all staff. The inspector was unable to access the computerised documents and reviewed the paperwork. On this visit the computerised system was fully implemented and no residents had a copy of their care plan. The organisation has instituted a computer system for patient records which has removed the use of paper documentation from the home. In doing so they have failed to recognise that the system is not configured to provide an individual care plan for residents which meets the National Treatment Agency service specification for care planning and the requirements of the National Minimum Standards for Younger Adults. The consequence of Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 12 this was that at the time of the inspection none of the 44 residents currently in treatment at the home had a plan of care which documented how individual needs were met; this also impacted on the appropriateness and effectiveness of any interventions initiated for the residents and, where a risk assessment identified a potential problem, there was no evidence of control measures being put in place to reduce the potential risks to residents and staff. An immediate requirement was issued in respect of this service failure and the home will be revisited to ensure compliance. The inspector spoke in depth with the acting manager and the head of counselling about this issue, both recognised the problem this has caused and expressed concerns about how quickly the computer system would be adjusted to meet the needs of the organisation rather than staff meeting the needs of the computer system. It was agreed that a care plan based on a Microsoft word document would be produced and tacked on to each resident individual record. This would mean that the positive aspects of the computer system, i.e. accessibility to records for all staff, would continue and also that service users can have a copy of their care plan and sign it to indicate their involvement and agreement. The issues of ensuring that preadmission assessments and referral documentation are scanned in on individual records must also be resolved so that each record is complete with all the information the home has on each resident maintained in one place. The daily records were seen and the quality of them was judged to be variable and this is attributed the to ability of staff to use the technology provided. This way of recording daily events is accessible for staff from any computer terminal and is a good aspect of the computer system. Two issues raised with the acting manager about the daily records were that the use of abbreviation is not acceptable, and that the programme needs to have a spell check facility included. Data protection measures are in place to protect confidentiality. The acting manager has addressed the problem with the risk assessments and produced a paper based system which expands on the information held on the computer system; this will identify risks and any control measures in place as well as any additional measures to reduce risk which must be included in the service user care plan. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.15.16.17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service continues to demonstrate a commitment to enabling residents to develop their skills; individuals are supported to identify their goals and work to achieve them. EVIDENCE: The evidence for this section was obtained b discussing with residents currently undertaking the programme at Broadway Lodge. The inspector spoke with resident in the primary stage and secondary stage of the programme. The home operates a programme of individual and group therapy, and group support so that the residents learn to deal with issues that arise for them and to support others. The residents confirmed this to the inspector and stated 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 a very positive role model. All of the residents stated that they had learnt about themselves, especially through doing their life story, and by receiving Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 14 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. Generally, despite the restrictions of the house rules, the service users were positive about the programme and about its benefits for their future health and well being. The areas where changes may improve the value of the service were for the opportunities in secondary care to be expanded to include access to fitness facilities and more educational facilities. The acting manager had already informed the inspector that the secondary care units were undergoing changes which include these issues. The residents were very enthusiastic about the quality of service provided by all levels of staff and the individual approach so that no one felt they were fitted into the programme, rather aspects of the programme were tailored to their needs. The food and meal provision continues to be good at the home. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff ensure that personal support is flexible, consistent and responsive to the changing needs of the residents. EVIDENCE: The comments made in the last inspection report for this section of standards are still valid. 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. The home is registered to provide nursing care to support residents through the detoxification programme; the treatment used is tailored to the individual, and their medical history. Whilst going through detoxification residents may require limited assistance with personal care, however personal care is not routinely provided. The home has a designated area for residents whilst detoxing, to allow them privacy. The inspector asked residents about their experience of the detoxification programme at Broadway Lodge, one resident Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 16 said they could not remember it, however they suffered no unpleasant side effects. Another resident confirmed that throughout their detox the support received from the nursing staff was exceptional, they were treated as an individual and felt that the nurses cared about them. The nursing staff were also praised for their skills in alternative therapies such as massage, auricular acupuncture and use of Hopi candles. The inspector was able to assess the procedures followed for residents with a dual diagnosis and was able to confirm that suitable arrangements were put into place with the local mental health services. The personal care received through the counsellor team was well received by residents who were able to see a counsellor daily for the first week of their treatment programme. The residents stated that the counsellors knew their job, and were able to support residents to identify their own strengths to work through problems. The management of medication administration was good. Residents in primary care have their medication administered by the staff. Clear and accurate records were maintained in regard to administration. One resident confirmed that on admission they had a wound that required regular dressing; the treatment received at the home has ensured that the wound has improved and no longer needs specialist treatment , the service user is now self caring. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and others associated with the service demonstrate a clear understanding of how to make a complaint, as they are aware of what can be expected to happen including response times. EVIDENCE: Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 18 All residents receive a copy of the home’s complaints procedure as part of their contract. Residents consulted told the inspector that they did not have any complaints and were able to talk through any concerns with the counsellors and nursing staff. They were confident that genuine concerns would be acted upon. The residents also have the opportunity to raised concerns at the house meetings or directly to the appointed house/group leader. The inspector was able to review the minutes of these meetings and note the actions taken. The home has a complaints record book and there has been one recorded complaint since the last inspection which is being dealt with by the acting Chief Executive. Policies were in place for the protection of vulnerable adults. There had not been any adult protection issues raised. The acting manager was able to show the inspector evidence of the clinical team attending training of awareness of child protection and has planned to update staff on adult protection procedures and protocols. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the residents. EVIDENCE: Broadway Lodge is an older building, with several newer houses making up the accommodation for secondary care. Although the accommodation receives heavy usage from the residents, there were no areas of concern to the inspector. The residents identified two areas where there could be improvement; lighting at the rear of secondary accommodation, and improved accessibility for those with mobility problems in secondary accommodation. This was discussed with the acting manager for action. The changes to the physical environment since the last visit are that the nurses offices are in the process of relocating. This will provide greater privacy and more space for a clinical room where alternative therapies can be used. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 20 The counsellors are now all on the same floor of the building which allows for better communication. The inspector confirmed the arrangements for residents smoking facilities at the home, and confirmed that the home was exempt from smoking legislation and is able to continue to have designated areas for smoking. The home is very clean and has a dedicated team of staff; the residents do have limited therapeutic duties around the home but are supported to achieve them by the domestic team. Management of the domestic team has now passed to housekeeping staff who have introduced a monitoring system to ensure standards are maintained. The acting manager and the inspector also briefly discussed the possibility of purchasing an additional property to use as an all female secondary treatment unit. Before this is put into action the inspector advised that the need for this type of service should be researched, as should the successful outcomes for service users, published research for this type of support would be available from the National Treatment Agency. The organisation would also need to ensure that the property met the National Minimum Standards for Younger Adults, in particular standards 24.3,24.4,24.11,25.7,25.8,27.3,28.2,30.2 before the property was registered. If the property is not registered then it would need to meet housing regulations for houses under multiple occupancy, but would be considered completely separate from the care home. Also consideration must be given to obtaining planning permission from the local authority. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a highly developed recruitment procedure that has the needs of people who use the service at its core. EVIDENCE: The staff at the home are settled and committed to provide a high standard of support to the service users. Recent management changes have been unsettling but the staff team has remained constant. This was confirmed by the residents who felt that the staff had worked well together and had provided continuity of support to them at a difficult time. Since the last visit the head of counselling has taken over responsibility for training; it was noted that training records for clinical staff had been updated and staff were able to attend a variety of courses. There have been no new staff who have started working at the home since the last inspection, the acting manager is aware of that the induction programme for all new clinical staff must reflect the common induction standards for care. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42,43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements for the home are in place on a temporary basis; lines of accountability within the home are not clearly identified. EVIDENCE: The temporary arrangements for the management of the home were put into place following the unexpected death of the Chief Executive, Graham Menzies. Currently Brian Dudley is acting Chief Executive and Company Secretary, whilst Stephanie Noble is the acting Registered Manager and nurse manager. Ms Noble has worked at the home for some considerable time and meets the requirements to be the registered manager as she is a registered nurse with the required management experience and is working toward completion of NVQ 4 in management. The organisation must provide written confirmation of this appointment as they have for Brian Dudley, and produce a job description Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 23 that reflects the responsibilities of the registered manager. The acting manager must also delegate some of the responsibilities from the nurse manager role to ensure she has sufficient time to act as registered manager. The acting manager, head of counselling and inspector discussed how the home was reflecting the additional elements of the programme which go toward providing a quality service. This should include the reflective practise that follows group therapy sessions and allows all of the clinical teams experience to be used to benefit residents; also the individual aspects of the programme should be emphasised as this is an indicator identified by the National Treatment Agency as contributing to the retention of service users in treatment. The exit questionnaire currently provides a grading system of the facilities at the home. It does not capture the positive experiences demonstrated to the inspector by the residents. The information from the exit questionnaire should be included as part of the business planning cycle and therefore should include the personal experience of residents who have completed treatment . The other aspect of quality assurance raised with the Chief Executive at the last inspection was analysis of early/disciplinary discharges and looking at how they could have been prevented or managed in a different way to support service users to remain in treatment. The internal quality monitoring and audits of areas of service provision are continuing, in particular the house meetings which allow residents to have direct input into the day to day running of the home. The records required by regulation have not been kept because of the changeover to a computerised system. The service users should have access to records held by them at the home and this should include care plans. Whatever system is adopted for the record keeping at the home it must be fit for purpose and staff using the system must feel confident about using it. The use of staff members to cascade training can be ineffective as it detracts from their main job role and there may be inconsistencies in how people are taught. The inspector discussed this aspect of service provision with the acting manager and the head of counselling who will be consulting with the system provider about changes that need to be made so that it fits the work of the organisation. The implementation of health and safety legislation at the home continues to be of a good standard. The fire safety risk assessment for the home was not available at the time of the inspection and the acting manager was advised that there needs to be an assessment in place which should reflect the management changes i.e. who is responsible, and the room changes. The inspector met with Stephanie Noble and Brian Dudley on 31 January 2007 and advised them to discuss the accountability and responsibilities of the home and ensure that these were clear. This task has not been completed and therefore it is unclear who is taking responsibility and what roles management Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 24 have in the home. The need for this is evidenced in the report , for example, responsibility for care plans would be the manager however there appeared to be confusion over what influence the manager had over the computer system and its effectiveness. Another example would be the potential purchase of additional premises without full consideration of the standards for new registrations. The acting manager and acting Chief Executive have worked together but must sort out areas of responsibility, and ensure this is endorsed by the board of trustees. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X 2 3 1 Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 26 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 YA6 YA41 YA7 Regulation 14,15,17 Requirement A clear plan of care for each individual resident must be produced which demonstrates service user involvement in the process. The acting manager and acting Chief Executive have worked together but must sort out areas of accountability and responsibility, and ensure the board of trustees endorses this. The organisation must provide written confirmation of this appointment, and produce a job description that reflects the responsibilities of the registered manager. Timescale for action 17/04/07 2 YA43 4(1)(C) Schedule 1 17/04/07 3 YA37 8(2) 39 17/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 27 1. 2. 3. 4. YA35 YA9 YA1 YA36 Induction of staff should be evidenced on individual staff files. Risk management should reflect the complexity of the needs of referred clients. Information about the home should be reviewed and potentially simplified. The supervision for counselling staff should be recorded with a clear distinction between professional and management supervision. Broadway Lodge DS0000020317.V332550.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 DS0000020317.V332550.R01.S.doc Version 5.2 Page 29 - 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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