Inspection on 01/12/05 for Broadway Nursing And Residential Home

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Broadway Nursing And Residential... 21/08/06

Broadway Nursing And Residential... 20/02/06

Broadway Nursing And Residential... 04/03/05

Broadway Nursing And Residential... 25/10/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Broadway Nursing And Residential Home 22-32 Flemington Avenue Liverpool Merseyside L4 8UD Lead Inspector Andrea Morris Unannounced Inspection 1st December 2005 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broadway Nursing And Residential Home Address 22-32 Flemington Avenue Liverpool Merseyside L4 8UD 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) 0151 270 2073 Flightcare Limited Brenda Henry Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 48 N 20 Personal Care in an overall total of 48 Date of last inspection 4th March 2005 Brief Description of the Service: Broadway Nursing and Residential Home was originally a school building that has been converted into a care home, which provides nursing and residential care for 48 older people. Broadway Nursing and Residential Home is owned and managed by Flightcare Limited. Bedroom accommodation comprises of 43 rooms of which 28 have en-suite facilities. Communal space within the home comprises of a large dining room and two lounge areas. Residents’ also have access to a garden area at the front of the building. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 4 hours. The inspectors spoke to residents’, family members, staff and the Manager. A tour was made of the home and examined documentation including residents’ files, staff files, policies and procedures, certificates relating to Health and Safety, and fire safety records. What the service does well: What has improved since the last inspection? What they could do better: Staff must ensure all handwritten signatures have two signatures so to protect residents’ from harm. Controlled drugs must be recorded appropriately so to ensure safety of residents’ and prevent possible abuse. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 6 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 Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6 Residents’ are only admitted to the home following a full assessment of their needs; this ensures the residents’ safety is protected. EVIDENCE: The home has an adequate Statement of Purpose that contains all the information required. All residents’ entering the home are in receipt of a written contract, this with the Service User guide clearly defines their terms and conditions of entering the home. Either the Manager carries out a pre-admission assessment or Deputy Manager to ensure the needs of each individual can be met. Potential residents’ are encouraged to visit the home prior to admission; they can if they wish stay for a few hours or a meal at no extra cost. The home does not provide intermediate care. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10,11 Care plans are well documented therefore safe guarding the residents’ welfare. Medication must be managed so to protect residents’ and prevent them from being put at risk of abuse. EVIDENCE: Individual care plans are created for each resident; all aspects of personal, social and health care are included. Care plans are reviewed at least monthly to ensure that the care for the individual is correct. There is a clear audit trail of accidents being logged and action taken. The home accesses support from other healthcare professionals as needed, including Physiotherapy, CPN (Community Psychiatric Nurses) and local hospital specialists. However, it was previously required that staff receive training in Dementia care due to the number of clients with early on set dementia, as yet no staff have received any dementia training. Medication was examined, it was noted that there was not two signatures on handwritten entries and that in the CD (Controlled Drugs) book there was drugs entered but no name against the medication this could leave the medication open to abuse. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 10 Evidence was seen during touring the home that staff respected residents’ dignity and privacy by knocking on residents’ doors before entering. Residents’ confirmed that they were able to choose how to spend their day and the staff respected their decisions. The homes policy relating to Care of the Dying is adequate and up to date. The Deputy Manager has completed Care of the Dying course, along with other staff having completed training in other aspects of palliative care including One day in Palliative Care, Syringe Driver training. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Activities are planned in conjunction with residents’ preferences so to promote choice and cultural satisfaction. EVIDENCE: The home employs an Activities Organiser for 10 hours per week. Activities are planned to suit the residents’ interests. Evidence was seen that the activities being delivered were varied; residents’ who spoke to the inspector stated they had particularly enjoyed making the Christmas cards. Entertainers also visit the home; residents’ confirmed they visit most months. There is a weekly church service held in the home, delivered by the Roman Catholic Church. The Church of England minister visits upon request. The home also has the mobile library that comes into the home on a monthly basis; several residents’ are using this facility at present. The home operates an open visiting policy, which enables residents’ to keep in touch with the local community and families. Residents’ stated that they felt they were able to express their views, a monthly residents’ meeting is held with the activities organiser and the chef also attends. The home has a three weekly menu rota; the chef regularly reviews this. Menus were considered to be balanced and wholesome. Residents’ stated they Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 12 enjoyed the food, they also stated that they could if preferred request an alterative to the daily option and that it would be provided. The daily menu is displayed in the Dining room on the notice board. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The home has a robust complaints procedure thus enabling the residents’ to be protected from potential abuse. EVIDENCE: The home has an adequate complaints procedure, which includes details of how to contact the Commission for Social Care Inspection. Complaints received into the home are recorded and an outcome is also included of what action has been taken. There have been no complaints received by the Commission for Social Care Inspection. The home usually has the local polling station on site to the home; this enables residents’ to attend with assistance if they choose. Most residents’ have selected the postal vote option, the staff will assist all residents’ in exercising their legal rights if they wish, and alternatively an independent advocate can be sourced to protect the individual. The home has recently purchased a training video on adult protection, some staff has already had the training and a questionnaire that accompanies the video demonstrates their understanding. The manager stated that all staff are planned to receive the training in the near future. The home has an adequate policy for Whistle blowing and adult protection. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 The home has refurbished all its communal bathrooms to ensure the safety and comfort of residents’ is maintained. EVIDENCE: The home has a ramp access so easy for wheelchairs. There is an ongoing redecoration programme for the home; some bedrooms have recently been redecorated. The corridors generally were well maintained however there is some damage to the decoration on the wall around the doorframe that leads to the section where the treatment room is, this does addressing. All the communal bathrooms and shower areas have been refurbished to a good standard, this will ensure the safety for all residents’. The home has adequate numbers of washing facilities for the residents’. The garden area is maintained to a good standard. The home has access to a gardener several times a week. It was noted that the home owns several types of pressure mattresses so to aid in pressure area care. The home is also able to provide profile beds so to Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 15 promote comfort and safety to those residents’ who are particularly assessed as in need. The bedrooms were found to be of a good size, many were able to accommodate some pieces of furniture of each resident. Staff encourages residents’ to bring in personal affects so to re-create their own home as much as possible. All the rooms viewed were found to be personalised The home was found to be clean and free from any unpleasant odours. However one area that does require attention is the flooring in the laundry this was found to be very dirty and stained, also the tiles around the washing machines were cracked and could possible cause injury to staff. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 All staff are checked against the Criminal Records Bureau (CRB) to ensure the safety of residents’ is protected. EVIDENCE: The home is well staffed, agency staff are only required for covering of shortterm sickness. Rotas were examined and it was noted that all shifts were staffed appropriately. 50 of care staff have completed their NVQ2 training, other staff are due to start in the New Year. There is a clear training matrix is maintained for all staff. A selection of staff personnel files were examined, there is an adequate policy for recruitment, however not all files were complete. All staff files must contain a photograph and proof of Identity as detailed in Schedule 2 of the National Minimum Care Standards. Evidence was seen that staff had been checked through CRB (Criminal Records Bureau). Residents’ and visitors both confirmed to the inspector that they felt the staff were both professional and helpful to their needs. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 37, 38 There is a strong sense of leadership, ensuring that staff are well directed to deliver high quality care to residents’. EVIDENCE: The registered manager is an experienced manager who has completed the Registered Managers Award. The Deputy Manager is currently completing her Registered Manager Award also. Staff who spoke to the inspector stated that the manager was very approachable and felt they had confidence in her. Residents’ also confirmed they found the manager approachable and helpful. The manager holds staff meetings on a three monthly basis. The home sends out a questionnaire to all families on an annual basis to assess the quality of the home. The home also is visited by ISO an independent Quality Assurance group yearly. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 18 The proprietor visits the home twice weekly, recording of the visits are maintained. Certificates relating to Health and Safety were examined and found to be in date. The fire logbook was also checked and evidence was seen of weekly fire testing and staff drills were also being recorded. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 N/a 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 N/a N/a 3 3 3 Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement The registered person must ensure that staff files contain all information including Identification, as detailed in Schedule 2 Care Home Regulations The registered person must ensure the safe recording of medication by instructing staff that handwritten amendments to medication records have 2 signatures supplied. The registered person must ensure that all fire doors in the home are not wedged open. The registered person must arrange for the laundry floor to be thoroughly cleaned or replaced if not able to clean, and tiles around the washing machines are repaired. The registered person must arrange for staff to be trained in Dementia care Timescale for action 20/12/05 2 OP9 13 20/12/05 3 4 OP38 OP26 23 13 05/12/05 31/12/05 5 OP7 18 31/01/06 Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 21 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 3 Refer to Standard OP3 OP18 OP11 Good Practice Recommendations It is strongly recommended that all pre-admission assessments are signed and dated so to evidence dates of assessment. It is strongly recommended that all staff including ancillary staff receive training in adult protection. It is recommended that all care staff receive training in care of the Dying, as the home has palliative care residents’. Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broadway Nursing And Residential Home DS0000025091.V270322.R01.S.doc Version 5.0 Page 23 - 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. 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