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Inspection on 20/02/06 for Broadway Nursing And Residential Home

Also see our care home review for Broadway Nursing And Residential Home for more information

This inspection was carried out on 20th February 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a homely and friendly atmosphere for residents` and visitors. Residents` stated they are very happy living in the home. Staff receive regular training in all aspects of care to assist in maintaining good standards of care.

What has improved since the last inspection?

The medication practices have since the last inspection improved. Records are maintained to a better standard. The decoration of several bedrooms has assisted in maintaining the home to a good standard.

What the care home could do better:

Care plans must be formulated as residents` develop new problems. Staff personnel files must contain all documentation as detailed in the National Minimum Standards schedule 2.

CARE HOMES FOR OLDER PEOPLE Broadway Nursing And Residential Home 22-32 Flemington Avenue Liverpool Merseyside L4 8UD Lead Inspector Andrea Morris Unannounced Inspection 20th February 2006 09:45 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.V284221.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 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.V284221.R01.S.doc Version 5.1 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 (48) of places Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 38 Nursing 10 Personal Care in an overall total of 48. One named person under the age of 65 years. Date of last inspection 1st December 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.V284221.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection; it was carried out over 4 hours. During the visit a tour was made of the home, the inspector spoke with the manager, residents and staff. A selection of documentation was also examined; including residents care files, staff personnel files, health and safety records including fire safety records. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be formulated as residents’ develop new problems. Staff personnel files must contain all documentation as detailed in the National Minimum Standards schedule 2. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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.V284221.R01.S.doc Version 5.1 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.V284221.R01.S.doc Version 5.1 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, 4, 5, 6 Residents’ are only admitted following a full assessment of their needs, this ensures the residents’ safety and interests are promoted. EVIDENCE: The homes statement of purpose and service user guide remains unchanged and contains all the relevant information as required. A copy of each is available upon request from the admin office. All residents’ admitted to the home is in receipt of a written contract, this clearly identifies the individuals terms and conditions of residency. The manager or deputy manager carries out a pre-admission assessment of all potential clients. No resident is admitted without prior assessment; this ensures residents’ needs are able to be met. Potential clients are encouraged to visit the home; they can if they choose stay for an afternoon or a meal at no additional charge. The home maintains records of all other healthcare professionals attending the home and delivering care. The chiropodist visits 6 weekly. The home accesses Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 Page 9 support from other specialists such as dietician, diabetic and tissue viability nurses as necessary. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 Page 10 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 files need to reflect all aspects of residents’ care. Medication practice has much improved thus promoting residents’ safety. EVIDENCE: A selection of care files were examined and found to be appropriate. Care plans that had been formulated were seen to be reviewed on a monthly basis. However it was noted that new problems that residents’ were experiencing did not have care plans devised. Risk assessments were seen to be relevant and reviewed on a monthly basis. The medication for the home was examined; this has improved since the last inspection. Medication was found to be correct and all documentation recorded correctly. Residents’ stated they felt they were treated well. Staff were respectful of their wishes and provided ‘good care’. Evidence was seen of the good rapport that staff and residents’ had between each other. Residents’ stated they enjoyed living in the home. The home has an adequate policy on care of the dying. Some staff have received training in care of the dying. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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 Residents’ are assisted in maintaining contact with their families and friends; this promotes their emotional well-being. EVIDENCE: Activities are carried out on a regular basis by the activities organiser who is employed for 10hours per week. Residents stated that they were able to choose if they wanted to participate and that staff respected their wishes. Activities are designed around the residents’ preferences and are varied. Visiting entertainers attend the home on a monthly basis. Bingo was being played on the day of the inspection and several residents had participated. Records are maintained to support all activities provided. The home also provides outing for residents’ if they choose to go, various places are visited and residents’ choices are taken into account. The home operates an open visiting policy; the Roman Catholic Church visits weekly, other dominations visit upon request. All residents’ stated they enjoyed the food. Menus are on a four weekly rota. They were seen to be well balanced and nutritious. Residents are able to choose additional food if they do not wish to take the options provided. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 Page 12 A recently held residents meeting enabled residents’ to change the menu to include food of their particular preference. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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 an adequate complaints policy; complaints are taken seriously and action taken recorded. EVIDENCE: The policy for complaints is displayed in the entrance area; copies are available upon request. There has been no complaints to the Commission for Social Care Inspection. All complaints received in the home are recorded along with the action taken. Residents’ entering the home are placed on the electoral role. Residents’ are able to attend the local polling station as it is always placed on the homes grounds, alternatively they can access the postal voting system. Residents are able to receive their post un-opened. Any resident requiring assistance can have staff open post; this is always done in front of the resident. All staff have received further training in adult protection. Adult protection training is also covered during the induction period. There have been no adult protection issues in the home since the last inspection. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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, 24, 26 Residents’ rooms are personalised; thus assisting in residents’ to feel at home. EVIDENCE: The home is well maintained; evidence of a re-decoration programme was seen. Several bedrooms have been re-decorated since the last inspection. The issues relating to the laundry have also been addressed and the area is much tidier and hygienic. There are plans for some internal building work to take place in the next few months following a problem with the chimney. Plaster is to be removed and the wall to be dried out then re-plastering and decoration to the corridor to follow. The home has ample ramps so for residents’ to be able to access outside. Many residents’ stated they enjoyed going in the garden in the summer months. Residents’ rooms were found to be personalised. Many rooms are large enough for residents’ to be able to bring in a little furniture. Residents’ stated Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 Page 15 they felt the staff respected their space and that they were treated with dignity. The home was found to be clean and non odorous. The communal areas were found to be tidy and homely. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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 The recruitment policy is adequate; however staff files must contain all information to assist in promoting resident safety. EVIDENCE: Staff rotas were examined and found to be accurate. Since the last inspection the staff number has increased by one as the dependency within the residents’ has increased. The home does not use agency staff on a regular basis. 62 care staff hold the NVQ2 in care or above. Plans for the existing staff to commence on the programme are in hand. Staff receive regular training in all aspects of care. Mandatory training is delivered and the manager monitors staff attendance. Training is also accessed externally also this includes continence, infection control. Staff are able to access additional support from the telephone advisory contact this includes advise on Peg feeds, tissue viability along with many other clinical issues. A selection of staff personnel files were examined. It was found that copies of staff identification as specified in Schedule 2 of the National Minimum Standards was missing. One recent staff member had no record of induction. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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, 33, 36, 37, 38 The home is well managed; thus promoting high standards of care. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. The manager holds the NVQ4 in management. The deputy manager is currently studying the NVQ4 in management. Staff who spoke with the inspector stated the manager is approachable and they had confidence in her. Residents’ who spoke with the inspector stated the manager was approachable and helpful. The home is audited annually by ISO 9001 (Quality assurance group). The home also sends out its own internal audit questionnaire to residents, their families and staff on a regular basis. Comments made are addressed wherever possible. Staff receive supervision sessions on a regular basis. A new team approach has been introduced to assist in ensuring all staff receive the recommended 6 sessions per year. All staff receive an annual appraisal. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 Page 18 Fire records were examined and found to be accurate. Staff receive regular fire drills so to ensure they retain knowledge. Broadway Nursing And Residential Home DS0000025091.V284221.R01.S.doc Version 5.1 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 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 N/a N/a N/a 3 N/a 3 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.V284221.R01.S.doc Version 5.1 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 2 Standard OP7 OP29 Regulation 15(2) (c) 19 (1) Requirement The registered person shall where appropriate revise the service users care plan. The registered person shall not employ a person to work in the care home unless he/she has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of schedule 2 The registered person shall ensure all persons employed to work in the care home receive training appropriate to the work they are to perform Timescale for action 01/03/06 01/03/06 3 OP29 18 (1) (c) 01/03/06 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 OP36 Good Practice Recommendations It is strongly recommended that the new supervision sessions be implemented and maintained to ensure all staff receive the 6 sessions as required in a year. DS0000025091.V284221.R01.S.doc Version 5.1 Page 21 Broadway Nursing And Residential Home 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.V284221.R01.S.doc Version 5.1 Page 22 - 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. 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