Inspection on 20/05/08 for Broadway Lodge

This inspection was carried out on 20th May 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Broadway Lodge 10/07/07

Broadway Lodge 19/07/06

Broadway Lodge 20/04/05

Broadway Lodge 20/01/05

Broadway Lodge 30/06/04

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Snydale Care Home

Hawkhills

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The Grove Waltham

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Broadway Lodge 151 Fulford Road Fulford York YO10 4HG Lead Inspector Denise Rouse Key Unannounced Inspection 20th May 2008 10:45 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.V365468.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.V365468.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadway Lodge Address 151 Fulford Road Fulford York YO10 4HG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01904 621884 Mr Houssen Mohamud Baccus Mrs Swadeka Mohamud Baccus Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th July 2007 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 pleasant gardens to the front and back with ramped access allowing disabled access. Limited car parking is available. The accommodation is over two floors and spread over two houses linked together by a corridor. There are single and double bedrooms available. The first floor is reached either by a flight of stairs or a passenger lift. The registered providers manage the day-to-day running of the home. Information is available in the service user guide and statement of purpose about the services the home has to offer. The last Inspection report is also made available to people. Weekly fees charged on the day of the site visit ranged from £362.71 to £490. This information was provided on 28thof May 2008. Extra charges are made for hairdressing and chiropody. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The accumulated evidence used in this report has included: • A review of the information held on the home’s file since its last key inspection. • Information submitted by the registered provider in the Annual Quality Assurance Assessment, which was picked up by the inspector from the home on 2 July 2008. • Surveys received from eight people living at the home, five relatives, one health care professional, one cleaner and three care staff. • Two unannounced visits to the home, carried out by one inspector, which lasted in total ten hours and ten minutes. And a separate visit made by the pharmacy inspector on 3 of June 2008 to look at the medication systems operating in the home. • Evidence was gained by direct observation during the site visits which involved talking with people living at the home, visitors, the proprietors and other members of staff. Inspection of records, including care profiles, medication administration records, staff files and some of the home’s policies and procedures. • What the service does well: The proprietors are dedicated and treat the people who live there as if they were part of their own family. People are well presented and they look clean and tidy and cared for. A wide variety of activities are available to people living in the home. Staff receive training to ensure that care is provided by staff who have relevant knowledge of how to give care safely. Environmental improvements are undertaken to ensure the home is pleasant for people living there and their relatives. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information made available to people about what the home has to offer must be accurate and reflect the services available. Care plans must be completed in enough detail to state peoples general and specific care needs. They must be individualised and person centred. Care staff must refer to these documents and clearly record all care being given, to ensure individualised person centred care is being delivered and that this meets the needs of each person. Care plans must be reviewed and updated, as people need change to ensure their current care needs are being met. Medication systems must be improved to comply with current guidance to ensure people’s health and well being is protected. Food labelling must be introduced to ensure people are receiving food that is safe to eat. Safeguarding policies and procedures must be reviewed by the proprietors to ensure the correct action would be taken if a safeguarding issue arose, in the future. The complaint policy should have the correct details on it for people to be able to contact the Commission for Social Care Inspection if they wish. Personal allowance accounts for people living in the home, must continue to be recorded with the balance of monies available to people clearly stated, to avoid confusion and ensure people are protected from financial abuse. Health and safety issues relating to fire safety and access to the ground floor of the building must be addressed, to ensure peoples safety. Hot water temperature for water available to people living in the home should be provided at a comfortable temperature and this required increasing. Staff should have all necessary information required to them in the form of contracts and handbook, and information about the working time directive, to ensure they know what is expected of them. Quality assurance systems in relation to care planning and medication must be improved to ensure people are receiving the care and medications they require to maintain their health. Broadway Lodge DS0000015790.V365468.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 DS0000015790.V365468.R01.S.doc Version 5.2 Page 8 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.V365468.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. (6 Not applicable) People who use this service experience adequate quality outcomes in this area. People are assessed prior to being admitted to the home, however written information about the home requires reviewing and updating, to help them make an informed choice about if this is the right place for them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Pre admission assessments are undertaken by one of the proprietors. People who visit the home can be assessed at this time, or the proprietor goes to the persons own home or the hospital. During this initial assessment questions are asked about the persons medical and social needs, although the proprietor stated nothing is written down at this assessment, and information about the home is not given. The proprietor prefers to give their full attention to the prospective resident. Information from this initial assessment is recorded on the proprietors return to the home. Whilst it is important people feel they are Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 10 being given someone’s full attention, vital information may be lost and this information should be recorded when the assessment is taking place. Information from the local authority and the hospital is gained to support the pre admission assessment. People are not accepted into the home if it is felt that their needs cannot be met. Those considering living in the home are able to spend time there and move in for a trial period. This ensures that they can experience the services the home has to offer them. Information in the service user guide and statement of purpose require reviewing and up dating. The statement of purpose had a lot of information missing from it and also stated (Point 7) “ Broadway Lodge provides services in the following categories of resident, Old Age and Dementia. This was discussed with the proprietors, who said they knew they were not registered for dementia, this misleads people. Those admitted to the home receive a contract, which helps them understand what services are provided. Surveys received from people living in the home indicated that all but one felt they had received enough information as the proprietors spend a lot of time with them and answer their questions. They also spent time with them to help them settle into their new home environment. One person spoken with said “ I came into the home just before Christmas and took to it immediately, it’s the best home I’ve ever had”. Intermediate care is not undertaken. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use this service experience poor quality outcomes in this area. People’s health and personal care needs are not recorded in enough detail to ensure their needs can be met. However specialist equipment is available and advice is gained from health care professionals where this is required. Medication practices in operation at the home do not protect people from possible harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The proprietors and care staff know the residents well. People looked well groomed and presented. However care plans inspected did not contain enough individualised, person centred information to make sure that people received the care that they required, they were not reviewed monthly or as the persons condition changed. This was a requirement following the last inspection. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 12 Daily entries are not made for each individual daily. People with special needs do not have them recorded as being met each day, so it is unclear from documentation if their individual needs are actually being acted upon. People spoken with said staff did not sit with them with to go through their care documentation. There was no written evidence to suggest that a review was held with people’s chosen representatives. However one relative did state that that they were happy with how the home dealt with their relatives care. Care plans must be discussed with people living in the home so that they can say what care they want, and how they want to receive this. This care must be reviewed monthly or as peoples needs change. Where people are unable to take part in this process, relatives or a chosen representative should be asked to take part. Shortfalls in the documentation inspected were discussed with the proprietors, who stated that they would rather ensure that people received the care they needed, even though they agreed that the documentation was important, the delivery of care would be the priority, this issue must be addressed to ensure all the care being given is recorded. A key worker system is in operation in the home. Advocacy information is also available and visitors from age concern visit some people residing at the home. Health care professional visit the home as required and the proprietors also take people to their local general practitioners surgery if they prefer this. Special equipment, such as airflow mattresses are available in the home, this ensures that people are not placed at risk of developing pressure sores. Hoists for bathing and moving and handling people are also provided. Accurate administration of medication is not consistently done. This means people are not getting their medication as prescribed, which may effect how their condition responds. Medication requiring cold temperatures is not stored securely. This means there is a risk that medication may be removed or tampered with and be unsafe to use. The medication policy needs to be reviewed. The current policy does not provide enough information for staff on current legislation and guidance to make sure that safe practices are followed. There is no record of staff authorised to administer medicines. This makes it difficult to identify who was involved in administration if a problem or error was to occur. There are no dividers between the medication administration records (MAR). Having dividers between MAR charts helps to reduce the risk of the medication being given to the wrong person. The quantity of medication that is used from one monthly cycle to another should be recorded on the new MAR. This makes sure there is a method of tracking how much medication has been administered and to know how much Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 13 stock there is. Accurate administration of medication is not consistently done. An audit of current stock and records showed that some medication had been signed for but not given. However handwritten entries and changes to medication on the MAR charts are accurately done. It is important to have accurate entries to make sure people get their medication correctly. At lunchtime it was observed that staff took the medications round and gave them to each person who required something. But the MAR was not consulted during this process. Staff then came to the office and asked for the MAR charts and then continued to sign for all the medications given. This is unsafe practice and was discussed on the second visit with the proprietors who stated that as from that moment this system would cease. Medications would be given to each individual by the staff and immediately the person had taken the medication then the MAR chart would be signed. A controlled medication had been delivered to the home for one person. Staff had not been informed by the pharmacist that this was a controlled medication. It had not been recorded in the Controlled Medication Register. Immediately this was pointed out to the staff and proprietor the medication was recorded in the register. A person prescribed pain-relieving patches had been not received there prescribed dose on one occasion. It is important that medication is given as prescribed to make sure that the symptoms the person is experiencing such as pain is well controlled. The medication trolley is stored behind a locked door, however it could not be attached to the wall. The proprietors have had a chain fitted to the treatment room wall so that the medication trolley could be secured. One person residing in the home had some medications in their bedroom. These were not prescribed on their MAR chart, and had not been received and recorded into the homes medication records. The persons relative had brought these items in. The proprietor spoke with the relative and these items were stored in the treatment room ready to be collected by the relative. This item if still required was to be prescribed and dispensed by the person’s local General practitioner. The storage of medication requiring cold temperatures was poor. A lockable box is kept in the kitchen fridge, and the key kept on top of the first aid box in the kitchen. This means that medicines in this fridge are at risk of being removed or tampered with and are therefore not kept securely. The date of opening of medicines with limited use once opened is not consistently recorded. For example one liquid with a limit of one month after opening did not have a date of opening written on. Without a system to record opening dates there is a risk that people may receive medication that was no longer safe to use. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 14 One person self-administers their inhalers. A risk assessment has been done but was missing details such as the medication they self-administer and whether an assessment on how the person uses the inhalers was done. This must be addressed. The person in charge of ordering medication must have sight of the prescriptions before a supply is made. The prescription is the authority for the staff to administer medication to the person. This also provides an opportunity to check if any new medicines or dose changes are included. Any problems with prescriptions can be addressed at this point rather than after the supply has been made. The checking of prescriptions is an important part of the management of medication. Staff involved in the administration of medication have had some level of training and the manager has arranged further training. This means that staff will understand how to handle and administer medicines safely. Such training should lead to a greater knowledge and understanding about the safe handling of medicines. People spoken with said that they felt their privacy and dignity was respected. Staff were seen to address people by their preferred name and to knock on peoples bedroom doors before entering. Double bedrooms have screens available between beds to ensure personal care being given is not witnessed by the other person sharing the bedroom. One person said “ The staff look after me like a baby, I am very happy and never been happier, I am usually in bed just after 7.00pm, I love my bed, I can go to bed and get up whenever I want, I can go and lay on my bed in the day”. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. People have access to a wide variety of activities to ensure their social needs are met. People are provided with a choice of food to ensure they receive a nutritious diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home does not have an activities co-ordinator. One of the proprietors plans all the activities these include a wide variety of events. Afternoon activities available include bingo, dominos, indoor skittles and netball. Once a month Tia Chi and chair exercises are provide for people who wish to take part. Televisions and music are provided in the communal lounges for people to use if they wish. Staff and the proprietors knew each individual well and put themselves out to ensure outings and trips to the shops occur. The proprietors regularly go shopping on peoples personal request and spend a great deal of time to ensure people have exactly what they want to buy. Whilst there are a lot of activities to keep people entertained, there was no evidence that peoples Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 16 social care needs were recorded in a care plan. This should be implemented to ensure peoples preferred social activities are being met. Trips out occur to The Farmers Cart, Eden Camp, Burmby Hall Gardens, and to the theatre. A trip is being planned for residents to visit the Millennium Bridge. Children from Fulford secondary school visit at Christmas time to sing to people in the home and they come at other times to talk with people living there. Special occasions’ are celebrated such as Valentines Day and “Birthday Girl Events” are held, these are parties with buffet for resident’s birthdays to which their family is invited. A birthday cake is also made. A Christmas party is held for all to enjoy and the proprietor takes people strawberry picking. He picks the fruit and the residents who go with him, eat it. One person said, “ I’m not allowed to go out on my own, I am a bit doddery. If I want to go out to the pub then my daughter takes me in a wheelchair”. Before the proprietors went on holiday they had an entertainer in and a buffet was held for everyone including peoples family. A great emphasis is placed on people being treated “as one of the family”. A hairdresser visits once a week and a chiropodist as required for peoples convenience. Visiting is open and people can go out with their relatives. People’s religious preferences and needs are recorded and acted upon. Holy communion is held at the home once a month and a number of residents go out to a local church club. Local clergy visit the home as people request. Funeral teas have been held at the home and residents are taken to fellow residents funerals if they wish to attend. The proprietors have also arranged funerals for bereaved relatives if required. People’s dietary needs are known and catered for. Menus are available for people to choose from. The lunch menu is displayed in the dining room. People can choose where to eat, either in their bedrooms, other lounge areas or the dining room. Meals provided are balanced and nutritious with home baking provided. One person commented, “ The food is all good” another said “ The food is wonderful we do get a choice, and last thing at night we get a cup of Horlicks”. It was identified at the last inspection food items in the fridge were not labelled and some dried goods had been decanted into storage containers which did not have the foods best by date recorded. On this inspection it was found that these issues had not been addressed and action should be taken to ensure that food storage systems protect peoples safety. People who require help with feeding are assisted by patient staff, however one member of staff stood up whilst feeding one person. The proprietor asked Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 17 her to sit whilst assisting with feeding, however on returning to the area, the member of staff was still stood up. However feeding was not hurried and there was some good staff interaction between the person and member of staff. Other staff were seen on the second visit kneeling at a persons side whilst giving them a drink. People requiring assistance would benefit from staff being at their eye level. One person said, “ I’m not allowed to go out on my own, I am a bit doddery. If I want to go out to the pub then my daughter takes me in a wheelchair”. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use this service experience adequate outcomes in this area. People feel comfortable to raise concerns. However the complaints policy and safeguarding policy required updating and the proprietors should ensure they understand their safeguarding policy and procedure. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a complaints procedure, which is displayed on a notice board, it required updating with the new contact details for the Commission for Social Care Inspection. There have been no complaints documented as being received at the care home since the last inspection. People spoken with said they feel they could raise any issues they had with the manager or staff, some said they would speak with their family first who would then raise any issues they may have. The home has a policy about safeguarding people in their care. However it required some updating to include contact details of the local Authority. One of the proprietors was asked what action would be undertaken is an allegation of abuse was to be received. Their response was not entirely correct and therefore, further understanding of this policy and correct actions to be taken were advised. Staff receive training in abuse awareness, those questioned about what they would do said they would refer the matter immediately to the Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 19 manager for action to be taken. One safeguarding issue has been raised recently with social services, who have attended the home to look at the issues raised. Following this staff must receive further training about abuse to ensure staff are aware of the importance of professional communication, at all times. Criminal record bureau checks are undertaken for all staff. This ensures that people living in the home are protected from staff, commencing at the home if they are not suitable to work in the care industry. Comments received included “ I’ve been to the boss with my troubles, she is a great lass, very fast at sorting things out, I love her to bits. Another person said, “ If I was not happy with something I could talk to the staff who are very good”. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use this service experience adequate outcomes in this area. People live in a home that is maintained, however there are some issues relating to access on the ground floor which should be addressed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Broadway lodge is homely and clean. Maintenance and improvements to the building are undertaken to ensure that it is always nice for people who live their and their visitors. People are asked about improvements, which are to be made to décor, and furnishings and staff and residents help choose the colours of carpets and paints used. There is a passenger lift available to allow people who are not mobile enough to negotiate the stairs access throughout all areas of the home. There is a Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 21 garden and garden furniture is available, ramps provide access to the garden for people in wheelchairs and those who require walking aids. A variety of lounges and dining space is available on the ground floor and a small quiet lounge on the first floor can be used for private visits and quiet time. There is a disabled shower room upstairs with a seat; this helps to meet peoples bathing needs. Easy chairs and dining chairs have protective covers on them. This was discussed with management and is to stop anyone who may have an accident from wetting the chair and gaining unpleasant odours in the home. There were no unpleasant aromas in any area of the home. However the use of these covers could suggest all people who live there have continence issues and may not be the best system to protect people privacy and dignity. A part time cleaner is employed. Care staff assists with some domestic duties, especially laundry. The laundry was inspected and infection control measures are in place for handling soiled items, however there was no soap or paper towels available for staff to use to wash their hands. In some areas of the home there was no soap for staff to wash their hands with, staff were using the soap of people who lived in the home. This was discussed with the proprietor and was rectified before the second site visit. There are two double bedrooms, which have screens between the beds to protect the sharing occupants privacy and dignity. All bedrooms have a lockable door and a lockable drawer so people can have secure space if they wish. Downstairs bedrooms have no window restrictors fitted; one bedroom has a patio door leading to the garden, which was left open whilst the bedroom was not occupied. It was discussed with the proprietors that this issue should be reviewed and a risk assessment should be undertaken to consider the possibility of people leaving the home or unauthorized persons gaining entry. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. People are looked after by adequate numbers of well-trained staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff are provided in sufficient numbers to meet peoples needs. A thorough recruitment process is followed which includes recording the outcome and responses from potential staff at interview, as well as undertaking all necessary references and criminal checks. This ensures people are protected from staff that may not be suitable to work in the care industry. Staff receive training at regular intervals to keep their knowledge and skills up to date, and help them provide good care to people living in the home. Ongoing training in all statutory areas is completed for all staff. A training matrix is about to be created this will help to ensure that staff are always up to date. Training in relation to fire prevention is given yearly by an outside contractor. It was suggested the proprietors should contact their fire officer and see if this required to be increased, to ensure peoples safety is protected. More than 90 of staff hold a National Vocational Qualification in Care, this helps to enhance the care being provided to people living in the home. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 23 Informal staff meetings occur at every handover, and occasionally separate staff meetings are held. Supervision and staff appraisal occurs this ensures staffs views are known and any training issues raised can be acted upon. A new staff contract and handbook has just been created. Staff however do not have the Working Time Directive information available to them in either document. It was suggested that placing a signed copy of this on each persons staff file would be beneficial. Some issues had been raised that some overseas staff could not communicate effectively. However staff spoken with communicated well, and the overseas staff spoken with appeared to understand what people were saying and acting on this information. One comment received was “ Some of the staff have difficulty understanding English, and I sometimes don’t understand them. But eventually they do all that I ask. They are very caring”. Another person said “ The staff have all learnt English, I can understand them better than some of our own countrymen”. And a third stated “ I like being here the staff are very good, I have no complaints, they do their very best I really praise them that is official”. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use this service experience poor quality outcomes in this area. People living in the home benefit from having dedicated proprietors, however quality assurance systems must be improved and health and safety issues raised must be addressed to ensure people’s safety is maintained. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The proprietors are dedicated and manage the home on a day-to-day basis and cover evenings and weekends on call as well as visiting people living in the home out of hours. They are experienced and undertake training courses to help keep them up to date. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 25 The service is monitored by the proprietors who have some formal auditing systems in place. They speak with visitors and people living in the home and address issues raised in this informal way. However they do not keep any records of these interactions, which should be recorded as part of their quality assurance system. A yearly questionnaire to people living in the home. The results of the surveys were not seen, although the management state they act on the feedback. Health care professionals are asked for their views about the home informally when they visit, however their feedback is not recorded. Quality assurance systems must be improved in relation to care plans and medications to ensure that shortfall identified can be quickly addressed before they place people at risk of harm. There are serious shortfalls in care planning and medication systems in operation in the home. The staff have ignored basic safe practices when giving and receiving medications and cut corners so that their jobs are easier. The proprietors have not implemented robust quality assurance checks in these areas which would have ensured that shortfalls would have been identified and action taken sooner to protect people. This must be addressed. Policies and procedures for safeguarding people and for medications required updating. These must be kept under review and staff must be monitored to ensure they are following this guidance to ensure people’s health and safety is protected. The statement of purpose is not up to date and has a lot of information missing, it must kept up to date and have all the correct details contained within it, to ensure people are kept fully informed. On the first site visit the proprietors were informed about the Key Lines Of Regulatory Assessment (KLORAS), they wished it to be recorded that they had not been informed about the KLORAS and had not seen them before. They gained a copy, which was evident in the home for the second site visit. They should ensure that they keep updated with information provided on the Commission for Social Care Inspection website. Regulation 37 forms are not being sent to the Commission for Social Care Inspection routinely, other than for if people fall and sustain a fracture or for unexpected deaths. Routine deaths and falls must be notified to the Commission for Social Care Inspection. Personal allowance accounts are available for people living in the home. Since the first site visit the system of recording these transactions has changed to show a clear running balance. This was changed as some balances checked initially were incorrect and the system was confusing and difficult to understand. This new system must be maintained. Health and safety checks are undertaken, however on the first site visit four fire doors were held open by inappropriate means. This was discussed with the Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 26 proprietor who immediately contacted their contractor who visited and is to ensure correct measures are adopted to keep people who live and work in the home safe. Fire checks are undertaken weekly with fire training given to staff by an external provider once a year. The proprietors should consult the fire and rescue services to ensure that this is adequate to protect people. Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 27 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 1 X 2 X X N/A 2 X X X X X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 1 X X 1 Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 15 (1) (2) Requirement Timescale for action 20/07/08 2 OP7 17(1)(3) Schedule 3 15 Information in the service user guide and statement of purpose must be reviewed and updated and contain all information as specified in Schedule 1. Clear information about the categories of registration being provided at the home must be stated. To ensure people can make an informed decision about if the home is the right place for them. Care plans must be developed to 20/07/08 be person cantered, be kept up to date, and be reviewed as a persons needs change, with the service user or their chosen representative. This will ensure that care staff clearly know the care and support they are to give to each person living in the home, and this must be recorded. 3 OP9 13 (2) Previous requirement not met. Medication systems in operation 20/07/08 in the home must comply with the Royal Pharmaceutical Society Guidelines. DS0000015790.V365468.R01.S.doc Version 5.2 Page 29 Broadway Lodge All medications being received must be prescribed and recorded as being received. Controlled medication received must be recorded in the controlled drug register. People must be given their medication individually as prescribed, staff must observe them taking it and this must be recorded for each individual as this process occurs. All medication must be administered as prescribed. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. A robust risk assessment must be in place when people selfadminister their medication. This makes sure people are taking their medication as prescribed. Medication must be stored securely and safely. A system for the safe handling of medication with limited use once opened must be in place. This makes sure that medicines are safe to administer. Management must ensure that the safeguarding policy is up to date, and contact details for the local authority are available. The proprietors must update themselves relating to correct action they must take if a safeguarding issue were to be raised. Staff must receive more training Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 30 4 OP18 18 (1) (c) (i) 20/07/08 5 OP31 24 6 OP35 17(2) Schedule 4(9) in relation to professional communication. Robust quality assurance systems must be implemented for reviewing the care documentation and medication systems in the home. To ensure any shortfalls found can be quickly and thoroughly addressed. The systems put in place to ensure that clear, accurate records are kept of money handed over for safekeeping must be maintained. All financial transactions undertaken on behalf of anyone living in the home must be documented so that a balance of cash is correct and people’s financial interests continue to be safeguarded. Fire doors must not be held open by inappropriate means. Advice must be sought to ensure the fire training being delivered in the home is frequent enough to protect the people who live there and the staff. Safe working practices must be implemented. Policies and procedures for safeguarding people and for medications must be updated and kept under review. Staff must be monitored to ensure they are following this guidance to ensure people’s health and safety is protected. 20/07/08 20/07/08 7 OP38 13 (4) (a) 20/07/08 8 OP38 12 (1) (a) 13 (6) 20/07/08 Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 31 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 OP3 OP9 Good Practice Recommendations Information offered at the pre admission assessment should be recorded at the time of the assessment. To ensure no important information is forgotten. The medication policy should be updated to reflect the activities that staff are currently doing and to make sure that staff are all working according to the latest requirements and guidance. A system should be in place to record medication carried over from the previous month. This helps to confirm that medication is being given as prescribed and when checking stock levels. Regular, monthly prescriptions should be seen before sending to the pharmacy. This makes sure a check can be made that all the medicines required have been listed and prevents people from being without. Peoples preferred social activities should be documented in a care plan to ensure that these are being met. Staff should ensure they position themselves at the person’s eye level when assisting people to eat and drink. Food that has been removed from its original packaging must have its “best by” date recorded. Items of food in the fridge must have “opening or made on” dates recorded to ensure people living in the home are eating food, which is safe to eat. The complaints procedure should be updated to reflect the new contact details for the Commission for Social Care Inspection. People’s safety should be reviewed to ensure unauthorized access is not gained to the home from downstairs bedroom windows or patio doors in one person’s bedroom. A system should be implemented which respects peoples dignity when using incontinence protection covers on chairs throughout the home. 2 3 OP12 OP15 4 5 6 OP16 OP19 OP26 Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 32 7 8 OP29 OP33 Hand washing facilities for staff should be provided in all areas on the home. Staff should be informed about the Working Time Directive and a copy of this document should be retained on their file. The proprietors should record the day-to-day quality assurance checks they are making in the home, and ensure people have access to the outcome of quality assurance checks being carried out in the home. Send in regulation 37 forms into the commission for all incidents and accidents that affect the well being of people living in the home. Hot water temperatures provided to people’s bedrooms should be supplied above 38 degrees centigrade and not exceeding 43.0 degrees centigrade. The fire and rescue services should be contacted to discuss if fire training provided annually is enough to safeguard people living in the home. 9 OP38 Broadway Lodge DS0000015790.V365468.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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