Inspection on 21/08/06 for Broadway Nursing And Residential Home

This inspection was carried out on 21st August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

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

Broadway Nursing And Residential... 01/12/05

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 21st August 2006 09:30 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.V297908.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V297908.R01.S.doc Version 5.2 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.V297908.R01.S.doc Version 5.2 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 20th February 2006 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.V297908.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, during the visit the inspector spoke with the manager, residents, staff and relatives who were visiting the home. A tour of the building was made, documentation was examined including care files, staff personnel files, health and safety records fire records and some policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: Medication practices need to be improved to ensure resident safety is maintained. Staff personnel files are needed to retain all information as detailed in schedule 2 of the National Minimum standards. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 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.V297908.R01.S.doc Version 5.2 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.V297908.R01.S.doc Version 5.2 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 assists in ensuring resident safety is maintained. EVIDENCE: The home has an adequate statement of purpose and Service User guide that gives concise information relating to the services the care home has to offer. All residents on admission receive a copy of the service User guide. A copy is displayed in the entrance area of the home and further copies can be obtained upon request from the office. All residents on entering the home are issued with a written contract that clearly details the terms and conditions of residency. All residents prior to entering the home are assessed by either the home manager or a suitably qualified designated person. Pre-admission assessments give clear guidance as to the needs and preferences to each individual entering the home. This assessment is then used to assist in the formulating of appropriate care plans. Prior to admission any potential resident and their families are encouraged to visit the home to assess its suitability. Visits can be unannounced and be on Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 9 more than one occasion. Potential residents are able to arrange to stay for an afternoon or a meal to help them decide on the right home. The home does not offer intermediate care. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 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 plans and risk assessments are created and reviewed on a regular basis, this assists in ensuring resident care remains appropriate to their individual needs. EVIDENCE: A selection of care files were examined and found to be of a good standard, care plans were formulated and contained details of residents’ preferences and specific needs. All care plans were reviewed on a monthly basis, however not all dates were written in full dated format, a recommendation has been made to ensure a maximum of four weekly reviews is carried out on all care files. Each resident has written risk assessments that are also reviewed on a monthly basis. Risk assessments were completed in relation to care plans and the continuous assessment of residents needs. The home records wound management care plans to a good standard, wounds are body mapped (identified on body picture where they are on the body) care plans are formulated and records of other healthcare professionals including tissue viability and dietician involvement in care. Medication was checked and it was found that generally medication stock control was well maintained, however, controlled drugs that should have been Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 11 removed from the home 2 weeks prior to the inspection were still in the CD cupboard, a requirement has been made in relation to this. Medication that has a short life, i.e. eye drops were found not to contain the date of opening on the bottles, and medication that required a residents pulse to be recorded did not have the pulse reading recorded on some of the residents. Requirements have been made to address these practices. Medication in the drug trolley was found to be correct and all residents’ drug sheets contained signatures appropriately. The fridge temperatures were recorded on a daily basis, and the treatment room was found to be secured with the appropriate locks. Residents who spoke with the inspector stated they were very happy with the care they received from the staff, staff respected any decisions made. One particular relative stated that her mother had the best care, on entering the home she was very weak, but the staff had assisted her mother to be able to get out of bed and she praised the staff highly in the care her mother was receiving. Other relatives who spoke with the inspector stated that the staff were very professional and that they felt their relative was receiving good care. The home has a suitable policy relating to care of the dying, some care staff have recently received training in care of the dying. The trained staff in the home have also completed care of the dying training and syringe driver relief training. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 12 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 The home maintains strong links with the community, this assists residents to lead a socially well-balanced lifestyles. EVIDENCE: Activities are provided on a regular basis in the home, each month a plan of activities is displayed in the entrance area, on the day of the inspection several residents were knitting squares for blankets, these are being produced for Liverpool Women’s’ Hospital Special Care Unit. Residents stated they were free to choose if they wanted to participate in activities, one resident stated he preferred to stay in his room and complete activities on an individual basis. The home also accesses outside entertainment, the residents confirmed the previous weeks entertainer was very good. The Roman Catholic Church visits for Communion each Friday, a visitor from the Church of England comes in each month, and communion is available upon request. The home also receives visits from the library each month. Some residents stated they used the facility and found it a ‘good thing’. All residents who spoke with the inspector confirmed they were very happy living in the home, they were able to choose how they spent their day. They stated the staff were friendly, and professional but also got to know them well. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 13 The meals are provided on a four weekly rota, there is currently a new menu being tried out, residents stated they were mainly happy with the options but the manager confirmed the head chef was monitoring residents likes and dislikes and making the necessary alterations to ensure all residents enjoyed their meals. The main dining area was found to be pleasant, the daily menu was displayed and a list of alternative choices is always displayed for residents to be able to access alternatives to the daily meals. Residents confirmed that they were able to choose an alternative and it was always provided. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 14 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 All staff receive annual adult protection training, this assists in protecting residents from potential harm. EVIDENCE: The home has an adequate complaints policy, all complaints received in the home are recorded and the action taken is also detailed. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. All residents entering the home are registered on the electoral register, the polling station is based on the homes site, so any resident who wishes to vote is able to visit the polling station. Some residents prefer to vote via the postal system, staff ensure residents retain their right to vote at all times. The home also displays details of independent Advocacy Agencies, residents and/or their families can make contact independently of the home if they choose, the details of the advocacy agency are displayed in the entrance area of the home. Since the last inspection all staff have completed Adult protection training, there are 3 new staff who are due to complete their training in the next four weeks. All staff receive training on adult protection during their induction period. There have been no adult protection referrals made since the last inspection. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 15 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 Residents are able to personalise their rooms, this assists them to settle into their environment and creates a homely atmosphere EVIDENCE: The home is generally well maintained, since the last inspection there has been some building work completed on the external building and the next stage of repair to the internal part of the home is due to commence in the next six weeks. Following this work there are plans for re-decoration to be made to the main corridors. During the inspection it was noted that the main lounge ceiling had a leak, a requirement has been made to ensure the ceiling is repaired and safe. All communal areas were found to be well maintained, residents are able to access the baths via the use of hoists in which all staff receive training to operate safely. The garden areas are well maintained, residents informed the inspector in better weather they have enjoyed spending time in the garden. Residents are able to access the gardens via use of ramps. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 16 All residents are able to enjoy their own room, the rooms are large and some residents have been able to bring in small pieces of furniture, all rooms seen were found to be personalised with residents’ own things. Since the last inspection the home has fitted new blinds to all rooms and some rooms have had new curtains fitted also. New furniture is currently being purchased for the home. The home was found to be clean and free from any unpleasant odours. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 17 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 Staff personnel files do not contain all evidence as required to ensure residents’ safety is maintained. EVIDENCE: Staff rotas were examined and found to be staffed appropriately, the home uses very little agency, only to cover last minute sickness. Staff recruitment was found to be adequate however on checking staff personnel files it was noted that not all information was available for inspection, a requirement has been made to address this matter. Staff receive an induction when commencing employment within the home, they are required to complete documentation to state they understand procedures and then they are placed to work along side a suitably experienced staff member. Staff training has been continuous since the last inspection, the home has arranged training sessions on all mandatory training including fire, moving and handling and adult protection through an outside agency. Next month some staff are due to undertake First Aid training. A recommendation for all staff to receive a copy of their job description has been made. 45 of care staff have completed their NVQ in care, currently eight care staff are on the NVQ programme with plans for more staff to enrol in the near future. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 18 Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 19 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, 34, 35, 36, 37, 38 The manager provides strong leadership skills, this assists in maintaining good standards of care for residents. EVIDENCE: The manager is registered with the Commission for Social Care Inspection; she has completed the NVQ in management along with the deputy manager who has recently completed her NVQ4. Staff, residents and relatives who spoke with the inspector stated they were very happy with the manager, she was approachable and fair. The manager was also reported to have good communication with all persons. The home operates good standards of care in relation to financial procedures, residents who have their personnel finances held in the homes safe were checked and all found to balance accordingly. Records were maintained to a good standard. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 20 Staff receive formal supervision on a bi-monthly basis. Records are maintained and held confidentially. The home reviews its policies and procedures on a regular basis, all new polices and procedures relating to staff are given to each staff member individually for them to keep up dated. The homes fire logbook was checked staff receive regular fire drill training. All staff have recently had their annual fire training up dated. The home maintenance records were examined and found to not record water temperature checks on a weekly basis as required for safety, a requirement has been made to address this issue. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 21 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 N/a 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 2 3 3 3 3 3 3 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 3 3 3 3 2 Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 01/09/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 1) All digoxin medication must have pulse recorded. 2) All short life medication must have dates recorded of opening to ensure the safety of residents. 3) All Controlled drugs must be returned in appropriate time scales. The registered person shall 30/08/06 ensure that the premises are of sound construction and kept in good state of repair. The registered person shall not 01/09/06 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 (Previous timescale 01/03/06) Requirement 2. OP19 23(2)(b) 3. OP29 19 (1) Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 23 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 OP7 OP9 OP30 Good Practice Recommendations It is strongly recommended that the dates of review be clearly documented and not just in the form of month and year. It is strongly recommended that an up to date photograph of each resident be placed in front of all drug sheets as to assist with the identification. It is strongly recommended that all staff are in receipt of their current job description. Broadway Nursing And Residential Home DS0000025091.V297908.R01.S.doc Version 5.2 Page 24 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.V297908.R01.S.doc Version 5.2 Page 25 - 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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