CARE HOME ADULTS 18-65
Broadway North Resource Centre Broadway North Walsall West Midlands WS1 2QA Lead Inspector
Lesley Webb Unannounced Inspection 7th February 2006 08:30 Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 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 North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 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 North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Broadway North Resource Centre Address Broadway North Walsall West Midlands WS1 2QA 01922-649640 01922-647829 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) Walsall Metropolitan Borough Council Mr Michael Hicklin Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 09 August 2005. Brief Description of the Service: Broadway North Resource Centre provides a short-term residential service for people with mental health problems aged 18-65. The residential sevices contains a Crisis Unit that 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 located on the first floor of the building (which also houses a day service and vaiours social care teams) and consists of nine single bedrooms, three of which have their own lounge areas, two communal kitchens, one having lowered work surfaces allowing for wheelchair access, two communal lounges, two bathrooms and two shower rooms. Additionally there are laundry facilities, a visitors lounge, recreation room and a private room for making and receiving telephone calls. Broadway North is located one and half miles from the centre of Walsall, facing the local Arboretum. The building is easily accessible from all areas by car, with local bus services running frequently from Walsall town centre. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 8.30am and stayed until 7.00pm. Time was spent talking in private to service users, formally interviewing staff, looking at records, observing care practices, sitting in a staff handover and discussing service provision with the registered manager. As this is the second inspection to take place in twelve months both this report and the one published in August 2005 should be read when looking at how the service is meeting national minimum standards. By the end of the visit the inspector was satisfied that generally Broadway North residential services offer a very good service and would like to thank everyone for their co-operation and assistance during the inspection process. What the service does well:
Staff at this service are very good at supporting service users to maintain their independence and accessing the local community. Service users can continue with employment and day care placements when accessing the service, with transport arranged if necessary. As a member of staff explained, “we recently had someone who was employed as a van driver access the service who continued with this whilst staying here. The whole point of what we do is to maintain and promote independence”. The service is also very good at promoting flexible routines. For example all people who access the service are allocated their own fridge and cupboards in the kitchen in order that they can plan, prepare and cook their own meals, ensuring choices are very individualised. All service users that the inspector spoke to praised this facility, for example one person stated, “Staff support us if we cannot cope, teach us new skills, build our confidence. We chose our own meals, buy our own food if we want, we have total freedom”. Additional praise was also given by service users about the manager and staff. As one service users stated, “they genuinely care, are there for you if you cry or if you’re happy. If you are not in the mood to socialise you can go to your room but if you’re in there for long the staff always come and knock the door and ask if your ok or want to talk,” and another, “if I’m at home and not well I can ring here and have a talk to someone, your never pushed away”. These comments were reinforced as the norm throughout the visit where the inspector witnessed staff interacting with service users in an informal yet supportive way, but still encouraging independence. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
No progress has been made for the responsible person to ensure that monthly visits in accordance with Regulation 26 of the Care Homes Regulations 2001 are undertaken despite this requirement first being identified in July 2002. The inspector is concerned that the local authority is not fulfilling its legal obligations in relation to this, resulting in an Immediate Requirement Notice being issued at the inspection. Due to this being a respite service where people bring their own medication, the home cannot implement a monitored dosage system for medication. This is raising issues in relation to policies and practices complying with relevant guidance and legislation. It has been arranged for the pharmacy inspector for the Commission for Social Care Inspection to visit the service in March 2006 after which the home must implement all requirements that may be made. Further work must also be undertaken to address all of the requirements contained within the fire departments report, provide training for staff in fire, food and health and safety and to implement a formal quality assurance system.
Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed at previous inspection. EVIDENCE: Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. New risk assessment documentation and processes, when fully implemented should promote service users independence within a risk-managed framework. EVIDENCE: It was noted by the inspector that a previous requirement to ensure risk assessments contain relevant information to the service provided by the home is partly met. The home has devised a new risk assessment format that will ensure information can be reviewed each time a service user accesses the service or if circumstances change. The inspector looks forward to seeing this document fully operational at the next visit. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. The home is excellent at supporting people with educational and employment needs, promoting independence based on each persons wishes and capabilities. Opportunities to access the local community are excellent, enriching service users lives. The rights and responsibilities of service users are well managed, creating an inclusive atmosphere for people who access the service. The management of meals is very good, with an abundance of evidence that service users are able to exercise choice and control over what they eat. EVIDENCE: The home is to be commended for its efforts to support service users with education and employment. Service users have access to the day centre (located within the same building as the residential service) where sessions including computers, cooking and relaxation can be undertaken. In addition to this it is the policy of the service that people in employment can continue with
Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 12 this whilst staying at the home. Service users are also supported to increase their independent living skills based on their capabilities. For example each person is supported to plan, prepare and cook their own meals, tend to their own laundry and clean their own rooms. As one member of staff explained, “these needs are identified in the assessment process and form part of the action plan. The whole point of what we do here is to maintain or promote independence”. The inspector was also informed that service users can access a benefits advisor who holds a monthly surgery in the daycentre if required. The staff are to be commended for their efforts to integrate the residents into the local community and to take part in all the activities that are available. There is an individual programme of leisure activities both within and outside the home for each resident. These include Shopping, cinema, clubs, hairdressers, bowling, parks and pubs. Support for service users to access the community varies; again depending on each persons needs but can include staff arranging transport such as local taxis and ring and ride or acting as an escort on public transport. As one service user explained, “staff encourage you to do everything and go the same places you would normally do if at home. Just because you’re here doesn’t mean you should stop living your life”. Information regarding visitors is contained in the homes brochure and on display within the unit. Due to the needs of people who access the service visitors are allowed between the hours of 9am and 9.30pm and are not allowed into the main residential areas but may use of one the lounge areas. Both staff and service users all confirmed the reasons for restricting visitors around the building; to safeguard potentially vulnerable people at times of crisis. The home should also be congratulated for efforts undertaken that ensure the daily routine of the service are flexible and tailored to each persons individual needs. All service users confirmed that they are given keys to their rooms and were also able to explain rules in relation to smoking, alcohol and drugs. Records also confirmed that this information is given to all service users either before or on admission in the information pack and is also in the terms of residency. Also all staff that were interviewed demonstrated in-depth knowledge and understanding of supporting service users to be independent and their rights to make choices. For example one member of staff stated, “At the initial assessment we look at capabilities and consider what they do when at home. We are mindful to respect their privacy but if at risk of self-harm we monitor. We encourage to cook for themselves, manage their own monies. It’s important to support people and not to do things they are capable of doing themselves. Offering all this choice ensures a flexible service”. The inspector instructed that the only area relating to choices and restrictions that also must be included in the homes brochures is that of pets. Observations and comments received by service users confirmed particular attention is given to resident’s individual preferences in regard to the food provided in the home. All the comments regarding the quality, quantity and
Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 13 variety of the food and meals were highly complimentary. The home does not employ a cook, residents are encouraged to self cater as part of their Care Plans. The home provides appropriate facilities and assistance to the residents regarding the provision of meals. Dietary needs although made reference to in the initial assessment are presently not looked at holistically in relation to health, social or environmental factors and the inspector strongly recommends this is reviewed and incorporated into the assessment process. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Although medication practices promote independence within a risk managed framework, further work is required to ensure systems are safe and comply with legislation. EVIDENCE: As this is a respite facility it cannot operate a monitored dosage system for medication. Service users bring their own medication with many selfmedicating unless the risk of self-harm is too great. The home is attempting to manage medication safety and in line with relevant guidance and legislation however arrangements were made during the inspection for a CSCI pharmacy inspector to visit the service in March 2006 to assess this standard in detail, after which a report will be published detailing any requirements that may have to be undertaken. When looking at medication the inspector found that many policies and procedures need either reviewing or implementing and that no staff currently hold accredited medication training (however arrangements for staff to undertake this were made during the inspection). The inspector instructed that a risk assessment be completed for the practice of unqualified staff administering medication. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The home has an excellent complaints system with evidence that service users views are listened to and acted upon. EVIDENCE: The inspector noted that adult protection training is booked for March 2006, addressing a requirement identified in the previous inspection. In addition to this the home has implemented a system for recording and monitoring of expressions of dissatisfaction made by service users as an aid to communication. This new system works in addition to the formal complaints procedures and evidences the open and inclusive approach to complaints management within the home. Service user meetings have also been instigated, again as yet another forum where people can express opinions and raise concerns. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Generally the standard of the environment within this home is good, providing service users with an attractive and homely place to live. Outstanding fire requirements have the potential to place service users at risk. EVIDENCE: Since the last inspection a quote has been obtained to improve directions relating to the location of the residential unit within the building and a new visitors book has been put into operation in order that effective monitoring can take place. A previous requirement to address all issues raised by the fire department is part met, with the minor work requirements in process. The inspector is however concerned that some aspects of the fire departments report remain outstanding, with no evidence that these will be addressed in a timely fashion. Without action being taken people who access the service are potentially at risk if a fire should occur. The home was found to be clean, tidy and free from any odour. The laundry room was inspected with the appropriate washing and drying facilities in place. The inspector did however instruct that personal protective equipment be available for use in this room and that hand washing procedures be prominently displayed. All staff that were interviewed demonstrated
Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 17 knowledge and understanding of infection control and their role in supporting service users in this area. This support was reinforced by service users that the inspector spoke to, for example one person stated, “staff support us, teach us new skills, build confidence. The tasks we learn like washing clothes properly we can take home”. Records seen by the inspector also confirm that the appropriate policies and procedures are in place and that the majority of staff have undertaken infection control training. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed at previous inspection. EVIDENCE: The inspector was impressed to find that staff meetings now occur every 6 weeks for both day and night staff (addressing a previous requirement). Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Management within this service is very good, providing consistent leadership, guidance and direction for staff. Although quality monitoring systems are in place these are not formalised or holistic and therefore the service cannot monitor fully that it is meeting its aims and objectives. Generally practices within this service promote and safeguard the health, safety and welfare of people. EVIDENCE: It was noted by the inspector that a previous requirement for the manager to complete the Registered Managers Award has now been met. Presently there is no formal quality assurance system in place. The Care Manager stated that the quality of service is monitored through observations, resident’s reviews, staff and residents meetings, and discussions with residents
Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 20 and their relatives and staff supervision. The home has produced a service users questionnaire, an annual development plan and there is a strategic plan that details objectives for the service. The inspector instructed that a formalised system must be introduced that includes analysing views of service users and stakeholders in the community and that also demonstrates all aspects of service provision including the environment are regularly monitored. A previous requirement that the registered person for the service ensures monthly visits in accordance with Regulation 26 of the Care Homes Regulations 2001 remains unmet. This requirement was first identified in 2002 with no evidence of any progression since that time. The inspector is very concerned that responsibility is not being taken by the local authority to fulfil its obligations in relation to this legislation and issued an Immediate Requirement Notice that must be complied with. Since the last inspection all staff have undertaken one fire, food hygiene, moving and handling and infection control training, with only first aid and health and safety now outstanding. In addition to this the home made arrangements for the environmental health department to visit, seeking advice in relation to kitchen facilities with no requirements made. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 2 X X 2 X Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 22 Yes Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 9 Requirement Information contained in service user risk assessments must be current and relevant to the service provided by the home – Part met. Requirement originally made August 2005. The home must implement a policy on pets. The home must implement any requirements made by the CSCI pharmacy inspector and review and amend its policies and procedure in line with requirements. The home must implement a risk assessment for unqualified staff administering medication. Improvements to directions relatingto the location within the building of the residential service must be made – Part met. Requirement originally made August 2005. All actions contained within the Fire Departments report must be acted upon – Part met. Requirement originally made August 2005. Personal protective equipment
DS0000036497.V282006.R01.S.doc Timescale for action 31/05/06 2 3 YA16 YA20 12(4) 13(2) 31/05/06 30/04/06 4 YA24 16(1) 31/05/06 5 YA24 16(1) 30/04/06 6 YA30 13(3) 14/02/06
Page 23 Broadway North Resource Centre Version 5.1 must be provided in the laundry. Handwashing instructions must be prominantly sited. A formalised quality assurance system must be implemented that meets all of standard 39 of the national mimimum standards for younger adults. The registered person must ensure that monthly visits in accordance with Regulation 26 are undertaken and a copy of the report fowarded to CSCI for inspection – Requirment originally made July 2002. All staff must undertake two fire training sessions per year, with records maintained – Part met. Requirement originally made August 2005. All staff must undertake first aid, food hygiene, moving and handling, health and safety and infection control training – Part met. Requirement originally made August 2005. 7 YA39 24 31/05/06 8 YA39 26 17/02/06 9 YA42 13(4) 31/05/06 10 YA42 13(4) 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA17 Good Practice Recommendations It is strongly recommended that nutritional assessments be expanded in relation to health, social and environmental factors. These should then be incorporated into assessments and action plans. Broadway North Resource Centre DS0000036497.V282006.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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