Inspection on 22/08/05 for Broadway Lodge

This inspection was carried out on 22nd August 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 07/11/07

Broadway Lodge 20/03/07

Broadway Lodge 05/12/06

Broadway Lodge 14/02/06

Broadway Lodge 15/02/05

Broadway Lodge 05/08/04

Broadway Lodge 08/03/04

Broadway Lodge 10/02/04

Similar services:

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 BS24 9NN Lead Inspector Nicola Hill Unannounced 22 August 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Broadway Lodge Address Totterdown Lane Off Oldmixon Road Weston-super-Lane North Somerset BS24 9NN 01934 812319 01934 815381 mailbox@broadwaylodge.org.uk Broadway Lodge Limited 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) Mrs Pauline Bissett Care Home 55 Category(ies) of 1. People with past and present drug registration, with number dependency. of places 2. People with past and present alcohol dependency. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 33 Primary Care and up to 22 Secondary Care persons with alcohol and drug dependency, eating disorder or co-dependency. 2. Staffing notice dated 15/12/2000 applies. 3. The manager must be a RN on part 1 or 12 of the NMC register. 4. Broadway Lodge may accommodate up to two residents who are over 65 for the rehabilitation programme. Date of last inspection 15 February 2005 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 D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection at Broadway Lodge took place with the Chief Executive, Pauline Bissett. The inspection focused on the admission processes to the home from the perspective of both the staff at the home and residents. The inspection lasted approximately 4 hours and involved the admissions staff, three new members of the counselling staff team and six residents from primary and secondary care. Broadway Lodge provides a high quality service and has a good reputation both locally and nationally for the provision of treatment for addiction. This was in evidence throughout the inspection and was reinforced by the residents currently following the programme. What the service does well: What has improved since the last inspection? The medication system at the home has been further refined so that a clear audit trail for all medications coming into the home is available. The reception area has been redecorated and refurbished and provides a welcoming first impression for visitors and residents. The staffing ratios in secondary care for counselling staff have been increased. The IT system is in the process of being reviewed and updated with a view to having electronic patient records. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 6 Broadway Lodge now have a wider registration category and can take two service users over 65 years of age. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4 The Statement of Purpose and Service User Guide provide prospective service users with details of the programme and services at Broadway Lodge. This is supported by a robust admissions procedure that is informative and supportive of service users wishing to attend the programme. EVIDENCE: The Chief Executive has reviewed the statement of purpose in respect of the staffing (updating the list) and inserting the new Mission Statement for the home. All prospective service users are provided with a service user guide, residents at the home confirmed this. The admissions team reinforces the information in the guide. The team ensure that the prospective service users understand what the programme entails and the expectations of service users who take the programme. The admissions process is the responsibility of the admissions department the manager of which holds a qualification in counselling. Prospective service users can make a telephone inquiry. At this point details are taken in relation to the type of addiction and health status. Based on this initial information a decision is taken whether or not to proceed to the next stage of the process. The majority of potential service users then visit Broadway Lodge and are interviewed in person. At this interview more information that covers all aspects of the potential service users’ life is obtained and recorded. It may be Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 9 appropriate for some potential service users to also be assessed at this point by medical or counselling staff. Less than 5 of potential service users undertake a telephone interview; this is usually due to their personal circumstances, for example those within the penal system. All potential admissions are reviewed at the weekly Treatment Team meeting, although the Chief Executive retains responsibility. On arrival at Broadway Lodge all new admissions have a medical assessment by the resident doctor and an assessment by the nursing team. New admissions also meet up with one of the counselling team on the day of arrival. The expectations of the programme and the house rules are reinforced on admission. The residents at Broadway Lodge are happy to support new arrivals and act as buddies for an initial period. The admissions process was reviewed with residents at Broadway Lodge, all of who had different experiences of the process. One resident who was interviewed by telephone felt that this was appropriate. The placement was made under pressure of time and it allowed the admission to take place within the timescale of the placement funders. Another resident attended in person for an assessment and found that the experience of seeing the home and meeting with the assessment team was very reassuring. This was felt to be positive as it took the fear of the unknown away. A further resident had not attended the primary stages of the programme at Broadway Lodge, but had joined the secondary stage of the programme. A personal visit was arranged for this person, however, it was stated that this was the only placement offered to them. Of the six residents who discussed this aspect of the service with the inspector, none had any concerns about the process and stated that because it was a staged process it allowed them to take in information in small amounts and not be overwhelmed. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 The systems for service user consultation at Broadway Lodge are good with a variety of evidence that indicates that service users views are both sought and acted upon. EVIDENCE: The discussions with residents indicated that there are regular meetings for all residents to attend. Residents in primary care attend the house meetings and are able to raise issues relating to the day-to-day running of the home for example, minor repairs. Within the groups, residents also raise issues of importance to them, for example allocating people to be buddies for new admissions. Within the secondary care the residents also have opportunities within their meetings to raise any issues of concern. There was also verbal evidence given to indicate that they were consulted on a re-admission of a resident who had left the programme. The minutes of the meetings were available to the inspector. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 11 The Chief Executive, as part of the quality assurance process, also reviews and collates the responses to questionnaires given to residents when they complete primary care. This forms the basis of the service development plan. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,15,16,17 Links with the local community are good and support the residents with social and educational opportunities through AA and NA. The meals in this home are good offering good choice and variety; the home is able to cater for any special dietary needs. EVIDENCE: Broadway Lodge is situated close to the local shops and facilities. The extent to which service users can access the community is dependant on the stage they are at in the programme. Service users are supported to go out into the community and participate in therapeutic activities, AA or NA in order to relate to the support networks available to them on discharge. Service Users spoken with found this acceptable and were happy that this represented an opportunity to them. Limited recreational facilities are provided, however, some service users reflected on the fact they would have preferred more recreation whilst others felt that detracted from the work they were there to do. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 13 Friends or family members are welcomed on Sundays with a programme of educational lectures provided by the home for them to attend. One service user felt that this assists to maintain family relationships as the lectures explain about the nature of addiction and the behaviour associated with it. The residents stated that meals were good with sufficient choice available to them. The residents in secondary care have money to purchase their own food as a group. The success of this depends on the peer support within the group, however, this is overseen by the counselling staff in secondary care to ensure the menu is planned sensibly and food supplies do not run out! Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The systems for administration of medication are clear with comprehensive arrangements in place to ensure service users medication needs are met. EVIDENCE: The medication systems for the home have been reviewed and can provide a clear audit trail. The ordering of individual medication for detoxification has been changed and stock medication is now used. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The complaints procedure in this home is good with information readily available to residents. EVIDENCE: There has been one area of concern raised to the home by a referring agency. This was investigated and responded to appropriately. There have been no adult protection incidents at this home. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The residents at Broadway Lodge have a safe environment that requires regular maintaining to keep it in good order. EVIDENCE: Since the last inspection decorating has been undertaken in the reception area and on a smaller scale around the home for example some bedroom doors have been repainted. The building is subject to heavy use and the charity employ a full-time handyman in order to maintain a good standard of decoration. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 36 The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: Since the last inspection Broadway Lodge has employed three new counselling staff. The inspector spoke with the staff about their recruitment and induction to the home. The recruitment process followed the established procedure and it was mentioned that the outcome of selection interviews were communicated to the candidates very promptly. The new staff were aware that a CRB check needed to be completed prior to them starting at Broadway Lodge, however, this did not appear to delay them starting at work. The three staff all have different work experience, for example one councillor was newly qualified but had worked at Broadway Lodge as a trainee. This meant that the induction for the staff was different, although they fulfil the same job role. The initial week consisted of shadowing different staff members and orientated them around the home. After this the rate at which the councillors took on their full responsibilities was dependent on the individual. This was acknowledged to be good practice and the new staff felt supported and competent in their role. Their experience of working as part of the team at Broadway Lodge was stated to be very positive, with good support of Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 18 colleagues and a pleasant environment in which to work. The supervision for new staff from the head of counselling was delayed because of sickness and the Chief Executive is aware of this. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39 The staff team have a very good understanding of the residents support needs through a programme of rehabilitation; this is evident from the positive comments from service users. EVIDENCE: The residents both in primary and secondary care spoke highly of the staff team and the ethos of the home. The residents were able to identify the leadership at the home and demonstrate that all the staff were approachable and would listened to them. The Chief Executive was able to supply the inspector with a summary of the exit questionnaires from primary care. The areas particularly identified, as being excellent were the admission process to Broadway Lodge, the counselling received and the professionalism of the staff team. The areas, which did not rate so well predominantly, are those, which are reliant on the resources outside the control of Broadway Lodge. For example the range of videos and books produced relating to recovery from addiction rated poorly as Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 20 the majority of them were produced in the 1970s. New material has not been readily available and some of the videos used are dated but contain the necessary information. Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Broadway Lodge Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x x x D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 22 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 23 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Broadway Lodge D53_D02 S20317 Broadway Lodge V225419 310805 Stage0.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!