Inspection on 07/11/07 for Broadway Lodge

This inspection was carried out on 7th November 2007.

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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Broadway Lodge 20/03/07

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

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 North Somerset BS24 9NN Lead Inspector Nicola Hill Unannounced Inspection 7th November 2007 09:30 Broadway Lodge DS0000020317.V351818.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.V351818.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.V351818.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 Mrs Stephanie Noble 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.V351818.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. Registered manager must be a RN on part 1 or 12 of the NMC register. Broadway Lodge may accommodate up to two people who are over 65 for the rehabilitation programme. 20th March 2007 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 primary and secondary care within the framework of the 12 Step Recovery Programme. The primary care is sited in the main building and is also able to offer nursing care support. The 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 people are able to visit and people can use the local primary care health centre services. The home has established strong links with the local AA and NA groups, which people attend at appropriate times in the programme. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We undertook the unannounced key inspection of Broadway Lodge with the registered manager, Stephanie Noble. We spent one day visiting the site and during this time we looked at various records, and spoke with staff and the people who use the service in both primary and secondary care. We also used information from the Annual Quality Assurance Assessment and questionnaires sent to people using the service to inform the judgments made in this report. The Pharmacy Inspector, Susan Fuller, whose observations have been included in this report, undertook part of the site visit. Broadway Lodge has been assessed as providing a good level of service. What the service does well: What has improved since the last inspection? Over the past year the service has developed to promote an individual personalised approach. This has been demonstrated by the adoption of a new care plan format that clearly identifies the interventions and support for the individual using the service. The physical environment has been improved and is regularly maintained, with replacement of furniture and fittings where necessary. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 6 The management structure has changed to separate the role of chief executive and registered manager; this has led to the development of a management team who have adopted a business plan that promotes the development of the services offered at Broadway Lodge. One of the initial actions from this plan will be the rebranding of the organisation. The internal computerised record keeping has been adopted and is working well so that individual daily records are easily accessed. The home is able to offer a wider range of alternative therapies to support people through the rehabilitation programme. 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. The summary of this inspection report can be made available in other formats on request. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Significant time and effort is spent making admission to the home personal and well managed. Prospective residents and their families are treated as individuals and with dignity and respect for the life changing decisions they need to make. There is a high value on responding to individual needs for information, reassurance and support. EVIDENCE: We discussed the information that is made available to people which informs them about the service offered at Broadway Lodge. The management team are in the process of replacing the documentation and updating the website. The organisation has a rebranding launch planned for the end of November. We looked at the new documentation and commented on its content. We discussed with the people who use the service how they chose the home. Some people stated that the choice was made on personal recommendation by health or social care professionals, or from friends who had themselves been at Broadway Lodge. Whilst other people had accessed the information available on the website. All of the people who spoke with us had obtained an understanding of what to expect whilst in treatment. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 9 The home has a dedicated admissions department. People can make a telephone inquiry to admissions and discuss programme. The staff record all inquiries and establish the type of addiction and health status of enquirers. If a person wishes to proceed, the next stage of the process for the majority of people is a visit Broadway Lodge and an assessment to establish their suitability for admission. At this interview information that covers all aspects of the person’s life is obtained and recorded. It may be appropriate for some people to be assessed at this point by medical staff to ensure that any health needs are fully assessed. All potential admissions are reviewed at the weekly Treatment Team meeting, and the registered manager signs the admission assessment. 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. On arrival at Broadway Lodge all new admissions have a medical assessment by the person 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. We discussed and were able to confirm that people followed the admission process. People stated that they felt the process to be thorough and it gave them confidence in the service. One person who spoke with us had joined the secondary stage of the programme. A personal visit to the home as part of the assessment process was arranged for this person. The care home contract for fee payments is made directly with the funding authorities. We saw evidence of financial assessments on people’s files that explained what contribution they were expected to make toward their placement. For those who are self-funding a full breakdown of the fee is available. The people at Broadway Lodge were a mixed ethnic group with an age range of 18-55. Equality and diversity is addressed at the initial interview and through the individual care planning. Most areas in the home for primary care are accessible to a wheelchair user; mobility access to secondary care is limited. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plan is developed with, and owned by, the individual, based on a full and up to date holistic assessment. The plan is person centred and focuses on the individual’s strengths and personal preferences. It celebrates the individual, their life experiences and sets out in detail how all their current requirements and aspirations are to be met through positive individualised support. EVIDENCE: Each person has a named counsellor and a named nurse; this enables staff to develop professional relationships with people who use the service. Following admission the named nurse and counsellor devise care plan with each individual. We were able to see that plans been signed by people using the service. The care plans are reviewed at regular intervals, and we were able to see documentary evidence that this process involved the people using the service. The people who spoke with us confirmed this process had taken place. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 11 The documentation currently in use clearly identifies therapeutic interventions and their outcomes. We were able to read the daily records and crossreferenced these to the care plan and the persons’ progression through the rehabilitation programme. This area of operation has improved since the last inspection, and the documentation now gives a full picture of the support provided to individuals. The home is using the internal computer system to maintain the daily records and this has worked very well. Risk assessments are made on an individual basis and are linked to the therapeutic interventions identified in the care plan. The risk assessments identify reasonable control measures and are agreed with people using the service. We discussed with the people who use the service their perception of the care planning process and the therapeutic interventions used to support their rehabilitation progress. The comments from people were positive, in primary care people recognise that the communication between the staff team was good and that this promoted continuity in support. The people currently in secondary care stated that they felt their treatment was less individual as group sanctions were used. The ethos of group therapy and responsibility whilst in secondary care was accepted but felt unfair. These comments were fed back to the registered manager. The group of people in secondary care were reminded that there was a complaint process available to them. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11-17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service has highly effective methods, which focus on involving people to take responsibility in all areas of their life, providing links to specialist support when needed. This includes developing and maintaining family and personal relationships. EVIDENCE: Broadway Lodge offers a holistic programme of treatment, which encompasses individual and group therapy, peer support and education. The aim of the programme is to support people to make essential lifestyle changes and decisions without depending on mood altering chemicals. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 13 The range of alternative therapies available to people using the service including Hopi candles and aromatherapy massage. The people using the service can request the alternative treatments; these are planned to compliment the therapeutic programme. We discussed with the people at the home the value of alternative therapies, and received an enthusiastic and positive response. People stated that the alternative therapies particularly when the detoxing promoted relaxation and reduced cravings. We also discussed the limitations on the individual because of the restrictions of the programme. One person was able to relate that they had been at Broadway Lodge earlier in the year but had been discharged because of a relapse. We discussed relapse from the programme and the process of disciplinary discharge. The person who spoke with us was of the opinion that the process that had been followed was fair as the home had a duty to care towards others. The house rules are very clear and are discussed with people admitted to the home prior and post admission. People also sign a contract stating that they understand the expectations of the programme and the restrictions on their personal freedom. The daily routines and house rules at the home were felt to be reasonable and necessary by all the people who spoke with us. The home use a buddy system used to introduce new people to the programme. The people took this very seriously as a responsible duty involved as it also indicated that the staff team had placed a level of trust on them. People are supported to go out into the community in ‘safe’ groups and participate in AA or NA groups in order to inform and prepare them to use this type of support network that is available to them on discharge. Those people in secondary care have the opportunity to access short educational courses and the local sports centre. People are also encouraged to become involved in the schools educational programme. Friends or family members are welcomed on Sundays with a programme of educational lectures provided by the home for them to attend. People stated that this assisted to maintain family relationships as the lectures explain about the nature of addiction and the behaviour associated with it. The people using the service stated that meals were good with sufficient choice available to them. The people in secondary care have money to purchase their own food as a group. Those who spoke with us found this acceptable and were happy that this represented an opportunity to them to develop budgeting and cookery skills. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each resident’s plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. The home has a good record of compliance with the receipt, administration, safekeeping, and disposal of Controlled Drugs. EVIDENCE: None of the people currently at Broadway Lodge requires support with personal care. All the people 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 people 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. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 15 The healthcare needs of the people at the home are met by the nursing and medical staff at the home. In addition to this all the people are registered as temporary patients at the locality health centre, and whilst in secondary care use the health centre for medical attention. Local healthcare facilities such as dentists are accessed by the home; Broadway Lodge has also developed a good relationship with the local Accident and Emergency department at Weston General hospital. Amongst the group of people in primary care there are several who are diabetic, and to attend the local diabetic clinic at the locality centre. The nursing staff monitors other people with specific healthcare needs such as bipolar disorder, closely and appropriate additional support with mental health care is obtained where necessary. We were able to read documentation relating to wound care and cross-referenced this information to care plans. Some of the people have health care needs which require external appointments such as hospital treatment, these needs are assessed on admission and local services accessed where possible. The people who use the service are supported to achieve optimum health and well-being, the home provides within the programme additional groups such as stress management, in order to promote good health. The pharmacist inspector looked at the handling of medication and made the following observations about the systems used at the home. Part of this inspection was to look at the handling of one group of medicines called Controlled Drugs. These medicines have some additional requirements for storage and record keeping to make sure they are looked after safely. In summary a suitable cupboard is used to store Controlled Drugs but some additional bolts are needed to make sure that the cupboard is fitted more securely. Records showed that these medicines had been looked after safely. However some improvements should be made to make sure that the records are easier to follow, reducing the risk of mistakes being made. Some out of date medicines need to be safely disposed of to make sure that they cannot be used. All people are registered with a local doctor. Broadway Lodge also has their own doctor so a doctor is available to see clients each weekday. The registered manager said that staff have developed a good relationship with the local health centre, including an out of hours service to the home. This helps them to provide good quality health care to their clients. Medicines are supplied by a local pharmacy. Broadway Lodge holds some stock medicines and others are prescribed on NHS prescriptions. Clients having secondary care treatment register as patients with a local doctor and order their own prescriptions, if they need medication. This helps them to become more independent. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 16 A homely remedy policy has been agreed with the doctors so that staff can give a number of medicines to treat minor ailments. Some action is needed to make sure that medicines that must be prescribed by a doctor are not included on this list. Secondary care clients are encouraged to look after their own medication. A policy for this, including a risk assessment, is used to make sure that the clients’ health is protected. Medicines are stored in a room, which is locked when unoccupied. Action is needed to make sure all the medicine cupboards and the fridge are locked so that only people who hold the medicine keys can access the medicines. The temperature of the medicine fridge is recorded daily and was in the safe range for storing medicines. A minimum/maximum thermometer should be obtained so that the temperatures can be monitored more accurately. Systems are in place so that staff can audit some of the medicines to check that they have been given as recorded. Some further action is recommended to allow all stock medicines to be audited. Clients are asked to come to the medicines room to ask for their medication. Changes to the location of this room have meant that the area used by clients waiting for their medicines has been improved. Medicines administration record sheets are handwritten and signed by the doctor. Records inspected showed that medicines are administered as prescribed by the doctor. Clear records are kept of the receipt of all medicines into Broadway Lodge. Records are kept of the disposal of unwanted medicines. Care staff must make sure that it is clear in the records when the disposal company collects the unwanted medicines. In addition to this report a letter has been sent to the registered manager to give them more detail about the pharmacists inspection. Broadway Lodge DS0000020317.V351818.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 good. This judgement has been made using available evidence including a visit to this service. Residents and others involved with the service say that they are happy with the service provision, feel safe and well supported by an organisation that has their protection and safety as a priority. EVIDENCE: The complaints process at Broadway Lodge is given to people who are admitted for treatment as part of their initial contract. There is also a weekly house meeting so that people have a forum to raise any day-to-day concerns about the home. We were able to read evidence that the weekly house meetings are documented and the management addresses the issues raised. We also looked at the complaint, which had been received by the home and noted that they had been resolved. Whilst the home were able to demonstrate that they responded to complaints appropriately, we discussed with the registered manager the necessity to keep the components of each complaint should be kept together so that the process adopted by the home can be audited and is transparent. For example, there was a detailed response to a complaint in the file but the initial details of the complaint had been placed on the complainants file. The home must also be able to demonstrate that complainants are satisfied with the response to their concerns by recording outcomes. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 18 We discussed with people who use the service how they would raise concerns; in particular the people in secondary care were unhappy with a group sanction. Whilst people were aware that there was a process in place, they were happier to discuss it amongst themselves and seek a resolution from within the group. People confirmed to us that the staff team were approachable, and that the home was a safe environment. The registered manager has also started to have regular meetings with people who use service to obtain feedback on how they personally felt about their treatment and identify any improvements that could be made. The staff team have undertaken training in handling of complaints, and have all attended abuse awareness workshops. Broadway Lodge DS0000020317.V351818.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 people who live there. EVIDENCE: Broadway Lodge is a Victorian property which has been sympathetically converted for use and provides services for the detoxification and primary care; the people undertaking secondary care are housed in five modern houses attached to the grounds. Since the last inspection the charity have invested in upgrading facilities, for example, the chairs in the lecture hall have all been replaced, a CCTV security entry phone has been installed in reception, and during a site visit we were able to observe redecoration of the quiet lounge. New developments on the site include the redesignation of the bookshop as a training area, and the planting of an herb garden for the benefit of the people who use the service. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 20 The No Smoking legislation has been applied to all secondary care houses and exterior provision has been made. There is a variety of communal space available to the people at the home; this includes a large dining area with smaller lounges for smokers and nonsmokers. There is also very pleasant reception area where people can receive visitors should they so wish. The furniture in the communal areas is comfortable and provides a variety of seating to meet the needs of the group. The groups and activities take place in the communal areas i.e. lecture hall, chapel area. The outdoor space at the rear and front of the house is accessible and is an area for people to use for smoking before dark. The rooms are individually and naturally ventilated with windows that have restricted opening. The rooms are centrally heated and where possible there is a thermostatic control accessible to the person. Emergency lighting is provided throughout the home. The areas of primary care we visited were home was very clean and free from offensive odours. The registered manager is aware of infection control measures, and some staff have undertaken in infection control. There are suitable laundry facilities available for the home. We observed personal protective equipment in use around the home. We also visited the secondary care provision and toured the houses with the house leader. The accommodation is on a domestic scale and well maintained. There is limited access for people who may have mobility problems. Broadway Lodge DS0000020317.V351818.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 excellent. This judgement has been made using available evidence including a visit to this service. There is a diverse staff team that has a balance of all the skills, knowledge and experience to meet the needs of people. There is evidence that they demonstrate a thorough understanding of the particular needs of people, and can deliver highly effective person centred care. EVIDENCE: The staff team at Broadway Lodge is a multidisciplinary team so that the service can support the comprehensive rehabilitation programme. The home traditionally has a very low staff turnover, and three people have been appointed to the home to work either as part of the nursing team or as part of the counselling team since the last inspection. We reviewed the recruitment process followed by the charity and noted that the process had been the followed in full with evidence of application forms, interview processes, references and CRB checks being completed prior to commencing work at the home. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 22 The expectation of the organisation is that the staff will maintain their professional registration by completion of training pertinent to their post. We were able to review the training and supervision records for all staff employed at Broadway Lodge. We discussed with the registered manager that some records were of a higher standard than others, and that one person in particular should be commended for the way in which they had recorded their personal development. The level of training and support available to staff working at the home is exceptional and ensures that the therapeutic treatments used at the home are contemporary and reflect good practice. The registered manager was able to provide us with a staff rota, which demonstrated that there are sufficient staff, nursing, counselling and ancillary, to maintain the support for people over a 24-hour basis. It was also noted that all staff have a dedicated paid handover time between shift changeovers. The people who use the service were extremely positive about the support received from the staff team. The people who use the service were also impressed at the experience of the staff team, and their knowledge of addiction and the rehabilitation processes. The staff team are supported in various ways, the most important being the strong team identity and support given through meetings such as the morning significant events discussion, and feedback sessions after therapy groups. Care and attention is given to team maintenance and development. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 23 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): 37,39,42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager communicates a clear sense of direction, is able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. EVIDENCE: The management of Broadway Lodge has undergone significant change in the previous year. The registered manager and chief executive roles have now been separated with defined job roles and responsibilities. The registered manager is part of a senior management team. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 24 The registered manager completed the Annual Quality Assurance Assessment prior to this key inspection and has clearly identified the factors that go toward provision of a high quality service. The planned developments for the service were also included and we have used some of this information to inform this report. The registered manager has undertaken training courses in order to keep her professional knowledge up-to-date and provided evidence of continued professional development. The registered manager oversees the day-to-day running of the home. People who use the service stated that they could go and speak to her if they had concerns. One person also stated that they felt it was important that the manager had approached them and asked them about the service and obtained their viewpoint. The home uses questionnaires that cover all aspects of the programme run at the home in both primary and secondary care, to provide feedback to the staff team, and further develop the service. In addition they are continuing with inhouse quality assurance i.e. monitoring the cleanliness of the home, and collection of statistical data to demonstrate the success of the service. The organisation continues to hold accreditation with EATA. The records examined on this visit include: Care files Daily records Health and safety records i.e. PAT Medication records including the storage and administration of controlled drugs Quality assurance questionnaires Staff recruitment, supervision and training records Records are stored securely in order that access to them is restricted. Individuals can access records on request to the registered manager. The records held on computer are password protected in accordance with the Data Protection Act 1998. To review the level of health and safety at the home we looked at maintenance records for equipment i.e. passenger lift, training records for first aid, manual handling, fire safety, food hygiene and the accident records retained at the home. There have been a number of minor accidents since the beginning of 2007; any minor incident, which had lead to treatment from an external agency, was reported to the Commission via the Regulation 37 process. Broadway Lodge is run as a charity and has a board of trustees who are accountable to the Charity Commission and ensure that the financial accounting meets the Charity Commission guidance. Broadway Lodge DS0000020317.V351818.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 3 2 3 3 3 4 3 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 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Broadway Lodge DS0000020317.V351818.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 YA20 Regulation 13.2 Requirement All medicines must be kept securely. This refers to: All medicine cupboards and the medicine fridge need to be locked. The Controlled Drugs cupboard needs to be attached using the correct bolts. Timescale for action 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA20 YA20 Good Practice Recommendations A minimum/maximum thermometer should be used to more accurately monitor the daily fridge temperature. Organisation of the Controlled Drugs register should be improved so that it is clear which medicines are stock and which belong to a specific client. When a new Controlled Drugs register is started all stock should be transferred to the new book, the transfer record should be checked and signed by a second nurse. This is to make sure that records in the new register are complete and correct. The accessibility of secondary care houses for those people DS0000020317.V351818.R01.S.doc Version 5.2 Page 27 3. YA24 Broadway Lodge with disabilities should be assessed. Broadway Lodge DS0000020317.V351818.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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.V351818.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. 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!