Inspection on 27/09/04 for Broadway North Resource Centre

Care Homes For Adults (18 ­ 65)Broadway North Resource CentreBroadway North Walsall West Midlands WS1 2QAAnnounced Inspection27th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Broadway North Resource Centre Address Broadway North, Walsall, West Midlands, WS1 2QA Email address Tel No: 01922-649640 Fax No: 01922-647829Name of registered provider(s)/company (if applicable) Walsall Metropolitan Borough Council Name of registered manager (if applicable) Mr Michael Hicklin Type of registration Care Home No. of places registered (if applicable) 10Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (10) Registration number E080000214 Date first registered 31st March 2003 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 31st March 2003 YES NO 2/10/2003 If Yes refer to Part CBroadway North Resource CentrePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th September 2004 08:30 am Ms Rosalind DennisID Code142283Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNA Mr Michael Hicklin; Registered ManagerBroadway North Resource CentrePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementBroadway North Resource CentrePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Broadway North Resource Centre. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Broadway North Resource CentrePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Broadway North Resource Centre provides a short-term residential and day service for people with mental health problems aged 18-65. The residential service contains a Crisis Unit which offers a twenty four hour response to the needs of adults experiencing mental health crisis, and a respite service which enables admissions to be planned throughout the year. The residential service is on the first floor of the premises, which is served by a lift. The home provides single bedrooms for all ten residents and there are three lounges, two visitors rooms and ample toilet and bathrooms. On the ground floor is a day service, which can be accessed by service users residing at Broadway North. The day service does not form part of the inspection by CSCI.Broadway North Resource CentrePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The focus of this years inspections undertaken by the CSCI is the experience and outcomes for service users, progress on meeting National Minimum Standards from last years inspections and focusing on aspects of service user provision that require further development, or pose the most significant risk to service users. Some standards may not have been inspected on this occasion and will be covered at the next inspection of this service. For a full overview of performance against the standards, this report should be read in conjunction with the previous report of the inspection undertaken on 2nd October 2003. This inspection was announced and was undertaken in September 2004 and involved a full tour of service user bedrooms and communal rooms. The inspector had opportunity to speak with two service users who were positive regarding all aspects of the home, services offered, the manager and staff. Eleven comments cards completed by service users that were received by the inspector prior to the inspection were positive; comments included the staff are very helpful, staff are friendly and approachable, this is a great service and the centre is a lifesaver. Two requirements were issued at this inspection, which demonstrates that, the manager and staff work hard to provide a service that meets the needs of service users and the National Minimum Standards. The Manager and staff are commended for the friendly helpful manner with which they welcome relatives and visitors. This was a good inspection and thanks are given to staff and service users for their assistance and welcome to the home. Choice of Home (Standards 1­5) 5 of the 5 standards assessed were met The statement of purpose is up to date and the home has a variety of leaflets for service users which provide detailed information of all the services offered Pre admission visits are encouraged whenever possible to enable prospective service users to view the home and meet the staff. To ensure that the home is able to meet service user needs, a comprehensive pre-admission assessment is undertaken. Discussion with service users, staff and examination of service user files indicate that the home is able to meet the assessed needs of the current service users. Individual Needs and Choices (Standards 6­10) 5 of the 5 standards assessed were met Risk assessments are conducted prior to and on admission to the home and service users Broadway North Resource Centre Page 6 are supported in decision-making regarding their lives. The home offers comprehensive, accessible information about activities and services available. Lifestyle (Standards 11­17) 7 of the 7 standards assessed were met Service users are supported and assisted to develop and maintain independent living skills. Support is given to enable service users to make use of services, facilities and activities available in the local community and service users are able to continue to participate in activities engaged in prior to admission as far as possible. Visitors are welcome at any reasonable time of day although service users are able to choose whom they see and when. Personal and Healthcare Support (Standards 18­21) 1 of the 1 standards assessed was met Service users are encouraged to maintain their independence with all daily living activities including hygiene needs. If personal hygiene care or nursing intervention is required then appropriate care is provided via relevant community services, for example, District Nurses. The inspector has requested that the CSCI pharmacist inspector visits the home to fully inspect the standard regarding medication. Concerns, Complaints and Protection (Standards 22­23) 1 of the 1 standards assessed were met The home has a clear and effective complaints policy that is in accordance with the local authority complaints system and meets the requirements of this standard. Environment (Standards 24­30) 9 of the 9 standards assessed were met The home is accessible to all service users and facilities are available to meet the needs of disabled service users. On the day of inspection service user rooms were personalised in accordance with their wishes and all areas of the home were clean. There are an adequate number of bathroom and toilets to meet the needs of service users. Several lounges are provided and there is a designated smoking area. Staffing (Standards 31­36) 5 of the 5 standards assessed were met Discussion with service users, staff and examination of duty rotas indicates that staffing and skill mix is sufficient to meet the needs of the current service users. Robust recruitment procedures are in place and the home has a designated structured and extensive induction and foundation-training programme that meets Sector Skills Council specification. Conduct and management of the home (Standards 37­43) 4 of the 7 standards assessed were met The manager has considerable experience in managing services for people with mental health problems. To fully meet this standard the manager is required to complete the Registered Managers Award or equivalent. On the day of inspection the inspector spoke with two service users who were positive about all aspects of the home, services offered, the manager and staff. Service users had been informed in advance about the planned inspection and 11 comments cards were received by the inspector prior to the inspection taking place. Broadway North Resource Centre Page 7 Monthly audits in accordance with Regulation 26 have not yet commenced and therefore remain in the outstanding requirements section of the report. A requirement was made for the temperature of the fridges and freezer in the service users kitchen to be monitored.Broadway North Resource CentrePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 26 YA39 The registered person must ensure that monthly visits in accordance with Regulation 26 are undertaken and a copy of the report forwarded to the CSCI for inspection. Not met New date 1/12/2004Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard NoneCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). None.MET (YES/NO)Broadway North Resource CentrePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 10 (3) YA37 The registered manager must complete the Registered Managers Award or equivalent. The registered person must ensure that the temperatures of the freezer and fridges are monitored on a daily basis to ensure that food is stored at the optimum temperature. Action taken to rectify any deviations in temperature must also be recorded. 01/03/2005213(3)YA4201/11/2004RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * None* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Broadway North Resource Centre Page 10 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES YES YES YES YES YES NO NA YES NO YES NO YES YES YES YES NO YES NO YES 2 0 1 NO NO YES YES 12 X 27/09/ 2004 09:00 6.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: Broadway North Resource Centre Page 11 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Broadway North Resource CentrePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 25.95 37.55 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 4 Key findings/Evidence Standard met? The statement of purpose is up to date and includes all the required information as detailed in Regulation 4, Schedule 1. The home has produced a variety of leaflets for service users, which provide detailed information of all of the services offered. The leaflets are well written, in a format that is clear and easy to read. The information is available in different formats and alternative languages if required.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Two service user files examined. Assessments are comprehensive and include assessments of mental and physical health, personal history and daily living skills. A support/ action plan is then formulated by the home in conjunction with the service user using information provided by the service user and relevant professionals. A copy of the CPA documentation is included on file.Broadway North Resource CentrePage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 4 Key findings/Evidence Standard met? To ensure that the home is able to meet service user needs, a comprehensive preadmission assessment is undertaken. Prospective service users are provided with clear information about the aims and purpose of admission. Information on the Crisis Unit and the Respite service are included in the service user guides. Discussion with service users, staff and examination of service user files indicate that the home is able to meet the assessed needs of the current service users. The home does not provide personal or nursing care. If required these needs are met through visiting healthcare professionals such as district nurses. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 4 Key findings/Evidence Standard met? Pre admission visits are encouraged whenever possible to enable prospective service users to view the home and meet the staff. Emergency admissions are accepted to the Crisis Unit following referral and assessment.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 4 Key findings/Evidence Standard met? Each service user is issued with a statement of the terms and conditions, which specifies all the information as detailed in NMS 5.2. This is discussed and agreed with the service user and signed by the service user and/or their representative. The Mission Statement, incorporating the aims and objectives for the home is included with the terms and conditions.Broadway North Resource CentrePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has an individualised plan, which covers all aspects of personal and social support, mental, and physical healthcare needs. The plan is drawn up from the range of clinical and risk assessments undertaken with the involvement of the service user as appropriate. The plan is reviewed and updated by staff on a regular basis.Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Service user file examined which demonstrated that service users are supported in decision making regarding their lives.Broadway North Resource CentrePage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The home offers comprehensive, accessible information about activities and services available. Due to the nature of the services offered, the service user group changes frequently. On the day of inspection service users appeared to have a good relationship with the manager and staff and appeared comfortable at expressing their opinions.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Risk assessments are conducted prior to and on admission to the home. Assessments of identified risk behaviour are incorporated into the individual plan. A procedure is available for staff to follow should service users go absent without prior agreement. This is clearly written within the terms of residence.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Service users files are kept secure and were clear, factual and appropriate on the day of inspection.Broadway North Resource CentrePage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 4 Key findings/Evidence Standard met? Service users are supported and assisted to develop and maintain independent living skills including cooking, social skills, and budgeting. Opportunity is given to fulfil spiritual and religious needs as needed. A number of service users are able to access day centre, college and other community facilities independently or supported by the homes staff.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 4 Key findings/Evidence Standard met? Service users are able to continue to participate in activities engaged in prior to admission as far as possible. The day service located on the ground floor offers a full range of activities to service users during their stay. Service users attending the centre may continue in their employment.Broadway North Resource CentrePage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 4 Key findings/Evidence Standard met? Support is given to enable service users to make use of services, facilities and activities available in the local community with staff accompanying as required; this is a recognised part of staff duties. The process of attending these activities may form part of the service users individual plan. The home is open for the free access to the grounds and local amenities by service users as they are able, in accordance with the terms of residence.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users are encouraged to continue with personal interests and hobbies. Activities will also be accessed depending on service user choice. The day service provides educational activities such as computer courses, catering training and employment support as well as complementary therapies and social activities.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 4 Key findings/Evidence Standard met? The home ensures that service users wishes are paramount. Visitors are welcome at any reasonable time of day although service users are able to choose whom they see and when. Visitors are requested not to access the main residential areas of the home.Broadway North Resource CentrePage 18 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 4 Key findings/Evidence Standard met? Broadway North aims to maximise service user independence therefore daily routines vary depending on individual service user needs and choice. Service users responsibility for housekeeping tasks is specified in the service user guide and the homes policy regarding general conduct, smoking and the consumption of alcohol are clearly stated in the terms of residence. Permission is sought from service users prior to staff accessing bedrooms; this was confirmed through discussion with the current service users. On the day of inspection staff were observed to treat service users with dignity and respect.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Each service user has access to an individual food storage cupboard and fridge. The process of shopping and catering forms part of the service users individual plan, with staff supervision if required. Socialisation with others is encouraged during mealtimes.Broadway North Resource CentrePage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Service users are encouraged to maintain their independence with all daily living activities including hygiene needs. If personal hygiene care or nursing intervention is required then appropriate care is provided via relevant community services, for example, District Nurses. Times for getting up/going to bed are flexible and agreed with the service user. Consistency and continuity within the home is maintained through designated keyworkers. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence This standard not assessed on this occasion. Standard met? 3X 0Broadway North Resource CentrePage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard not assessed on this occasion. The inspector has requested that the CSCI pharmacist inspector visits the home to fully inspect this standard.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard not assessed on this occasion.Broadway North Resource CentrePage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 0 X 3 Key findings/Evidence Standard met? The home has a clear and effective complaints policy that is in accordance with the local authority complaints system and meets the requirements of this standard. The complaints procedure is included in the service user guide and additional leaflets detailing the complaints procedure are available throughout the home. Advocacy services are facilitated if required.Broadway North Resource CentrePage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence This standard not assessed on this occasion. YES0 Standard met? 0Broadway North Resource CentrePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? On the day of inspection the home was clean; heating, lighting and ventilation appeared adequate. The previous requirement to attend to external paintwork and rendering has been met. The home is accessible to all service users and facilities are available to meet the needs of disabled service users.Broadway North Resource CentrePage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 10 0 0 X 10 0X X X X3 Key findings/Evidence Standard met? Useable floor space is sufficient to meet individual needs and lifestyles. The layout of individual rooms can be altered depending on the needs and request of the service user.Broadway North Resource CentrePage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? On the day of inspection service user rooms were personalised in accordance with their wishes. Furniture and fittings appeared suitable to meet individual needs and service users spoken with appeared happy with their rooms and the fittings provided.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home complies with the National Minimum Standards regarding numbers of bathrooms and toilets.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 4 Key findings/Evidence Standard met? The home exceeds the National Minimum Standards in regards to the size of the communal rooms. A range of shared spaces is provided including a designated smoking area. Sufficient and suitable furniture is provided in all communal areas. Adequate facilities are provided for staff.Broadway North Resource CentrePage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home offers facilities to meet the assessed needs of service users including individuals with a physical disability, for example lowered work surfaces in kitchen, walk in shower. The home will refer service users to specialist supporting services such as occupational therapists or physiotherapist if required.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? On the day of inspection all areas of the home were clean and free from offensive odours. Service users are responsible for ensuring their own bedroom and communal areas are clean.Broadway North Resource CentrePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Job descriptions examined for two members of staff appeared satisfactory for their role and appeared to support the underlying values of the home. Volunteers do not visit this home.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard not assessed on this occasion.Broadway North Resource CentrePage 28 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 0 5 2 366 9 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 0 260 106 366 Nursing X X XXX3 Key findings/Evidence Standard met? The staffing calculation above is based on information provided by the registered person in the pre-inspection report and is calculated according to the needs of 7 service users. Staffing within the home has recently been reviewed and meets the previous requirement to have two waking night staff on duty. Discussion with service users, staff and examination of duty rotas indicates that staffing and skill mix is sufficient to meet the needs of the current service users. The home has a stable group of staff and has required minimal Agency staff in the past eight weeks. Regular staff team meetings take place and are minuted.Broadway North Resource CentrePage 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Robust recruitment procedures are in place. Staff records indicate that two written references have been obtained and criminal records bureau disclosure undertaken for all staff. A recent photograph of each staff member is secured to his or her personal file.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The senior care manager has devised a comprehensive training matrix, which incorporates training profiles and training development plans for all staff. The home has a designated structured and extensive induction and foundation-training programme that meets Sector Skills Council specification.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The manager has cascaded supervisory responsibilities to the team leaders within the home. Supervision notes for care staff seen by the inspector, which demonstrated that formal supervision has been available for the majority of staff on a regular basis. The manager has recently undertaken individual performance reviews for all staff. Policies and procedures are available for staff to read.Broadway North Resource CentrePage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The manager has considerable experience in managing services for people with mental health problems and holds a postgraduate certificate in mental health and a certificate in management studies. To fully meet this standard the manager must complete the Registered Managers Award or equivalent. There are clear lines of accountability within the home and external management.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? The manager appears to demonstrate a clear sense of direction and leadership. On the day of inspection the inspector spoke with two service users who were positive about all aspects of the home, services offered, the manager and staff. Eleven comments cards completed by service users that were received by the inspector prior to the inspection were positive; comments included the staff are very helpful, staff are friendly and approachable, this is a great service and the centre is a lifesaver.Broadway North Resource CentrePage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The home has devised service user satisfaction surveys and anticipates that these will be distributed to all service users that access the service. Feedback is currently sought from service users on an informal basis. Service users had been informed in advance about the planned inspection and 11 comments cards were received by the inspector prior to the inspection taking place. Monthly audits in accordance with Regulation 26 have not yet commenced and therefore remain in the outstanding requirements section of the report.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The home has a comprehensive set of policies and procedures, which comply with current legislation and recognised professional standards.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? Records required by Regulation were well maintained, up to date and secure. Service user records were also in good order and secure.Broadway North Resource CentrePage 32 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Records seen and examined; evidence of regular servicing and maintenance of equipment including all portable electrical appliances, fire alarm/emergency lighting tests and water temperature monitoring. Risk assessments have been conducted for all safe working practices and access to relevant health and safety legislation is available. All accidents, injuries and incidents are recorded accurately and the CSCI informed when necessary. Training and updates regarding safe working practices topics are provided. The temperature of the fridges and freezer in the service users kitchen are not currently monitored. The registered person must ensure that the temperatures are monitored on a daily basis to ensure that food is stored at the optimum temperature. Action taken to rectify any deviations in temperature must also be recorded. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? Appropriate insurance cover is in place. The 2002/2004 development plan for the home appears achievable.Broadway North Resource CentrePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateRosalind Dennis Marie Harris 25th November 2004Signature Signature SignatureBroadway North Resource CentrePage 34 Public reports It should be noted that all CSCI inspection reports are public documents.Broadway North Resource CentrePage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27TH September 2004 of Broadway North Resource Centre and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBroadway North Resource CentrePage 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Broadway North Resource CentrePage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Broadway North Resource Centre confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Broadway North Resource CentrePage 38 Broadway North Resource Centre / 27th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000036497.V176752.R01© This report may only be used in its entirety. 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