Inspection on 15/01/07 for Broadway Residential Home

This inspection was carried out on 15th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Residential Home 20/02/06

Broadway Residential Home 30/11/05

Broadway Residential Home 02/03/05

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 Residential Home 22-32 Flemington Avenue Liverpool Merseyside L4 8UD Lead Inspector Andrea Morris Unannounced Inspection 10:30 15 January 2007 th 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 Residential Home DS0000025332.V313540.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 Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broadway 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 0151 226 2212 Flightcare Limited Sharon Rogan Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Broadway Residential Home is a care home that provides personal care and accommodation for up to 17 older people. Broadway Residential Home is located on the same site as Broadway Nursing Home and is one of six care homes owned by Flightcare Limited. The home is located in the Norris Green area of Liverpool and is close to local amenities and within easy access to bus routes. The home is a single storey building, which has been converted from an old school into its present day function as a residential care home. There are 17 single bedrooms, two of which have en-suite facilities. All the bedrooms are particularly spacious and the majority contain additional items of personal furniture. Communal space within the home consists of two lounges, a small lounge and a larger lounge with a dining area. The home also benefits from a wellmaintained garden that residents’ can easily access. Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection that took place over 4 hours. During the inspection a selection of documentation was examined, including care files, medication, health and safety certificates, staff personnel files, training records and financial records.. The inspector toured the home and spoke to residents, staff, the deputy manager, the home manager and the proprietor. What the service does well: What has improved since the last inspection? What they could do better: There have been no requirements or recommendations made in this inspection. Broadway Residential Home DS0000025332.V313540.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 Residential Home DS0000025332.V313540.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 Residential Home DS0000025332.V313540.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, 4, 5, 6 Residents’ are only admitted following a full assessment of there needs, this ensures the residents’ safety and interests are promoted. EVIDENCE: The homes statement of purpose and service user guide contains all the relevant information as required. A copy of each is available upon request from the admin office, copies are also being placed in residents rooms and being made available for potential residents when visiting the home. 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 can 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 Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 9 support from other specialists such as dietician, diabetic and tissue viability nurses as necessary. The home does not provide intermediate care. Broadway Residential Home DS0000025332.V313540.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 files are maintained to a good standard. Reviews of care are carried out monthly; this ensures residents’ care is correct. EVIDENCE: A selection of care files were examined and found to be maintained to a good standard. Care plans and risk assessments are reviewed on a monthly basis. Evidence was seen of other healthcare professionals involvement in residents care. The homes medication policy is adequate. A random selection of residents’ medication was examined and found to be recorded correctly. Drug stocks are controlled well. A clear audit trail is evident and staff have received training in medication administration. Controlled drugs are maintained safely and records were found to be correct. Residents’ who spoke with the inspector stated they felt staff treated them well. Many praised the staff and stated they enjoyed living in the home. Residents’ also reported that the staff are professional and friendly towards them. The homes policy relating to Care of the Dying remains relevant and contains all the necessary information for staff. Since the last inspection staff have Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 11 received training in Care of the Dying and records relating to the training were seen. Broadway Residential Home DS0000025332.V313540.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 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 10 hours per week in an afternoon . 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. New documentation is being introduced to ensure all activities either accepted or refused are recorded for each individual resident. 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 Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 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 Staff receive regular training in adult protection, this assists in safeguarding residents from potential harm. 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 and the achieved outcome. 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 receive training in adult protection on an annual basis. Adult protection training is also covered during the induction period. There have been no adult protection issues in the home since the last inspection. The home has a copy of the Liverpool Adult protection policy in the home. Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 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 is maintained to an adequate standard, this assists in providing a safe and pleasant environment for all residents. EVIDENCE: The home is maintained to an adequate standard. Evidence of a re-decoration programme was seen. There are plans to redecorate the main corridor and to replace the carpet also. Residents’ are able to access the garden area safely via ramps. Handrails are fitted throughout the home. All bathrooms are well maintained. Staff are able to have access to hoists to promote residents’ safety at all times. Many residents’ rooms were seen. The rooms are large in size and many residents’ have been able to bring in pieces of furniture to provide a sitting area also. All rooms were found to be personalised and residents stated this helped them to settle in and made it feel more homely. The home was found to be clean and free from any unpleasant odours. Residents stated they found the home a pleasant environment to live in, one resident stated she ‘loved’ her room and enjoyed spending time in it. Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 15 Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 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 procedure for recruitment is satisfactory and assists in promoting residents’ safety and protection. EVIDENCE: The staff rota was examined and found to be accurate. The home does not use agency staff on a regular basis. A selection of staff files was examined; the policy for recruiting staff assists with promoting residents’ safety. All staff are CRB (Criminal records bureau) checked. Staff files contained the necessary information and staff were screened appropriately prior to commencement of employment. Training files for all staff were maintained; staff receive training through the in house training system. Training is also sourced from outside agencies as necessary. Staff since the last inspection have received training in First Aid, Fire training, patient handling, adult protection and care of the dying. Training records are held in each staff file. 100 of the care staff hold NVQ2 or above in care. All certificates were available for inspection. Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 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, 34, 35, 36, 37, 38 The home is well managed; staff receive guidance and support 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. Staff who spoke with the inspector stated the manager is fair and a team player. 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 both residents, their families and staff on a regular basis. Comments made are addressed wherever possible. Since the last inspection the Company has introduced an internal audit of homes to be completed by the managers, this assists in ensuring standards are maintained and developed as necessary. Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 18 Staff receive supervision sessions on a regular basis. All staff receive an annual appraisal. Fire records were examined and found to be accurate. Staff receive regular fire drills to ensure they retain knowledge. The homes certificates relating to Health and Safety were examined and all found to be in date and appropriate. The home holds residents personal money as requested by residents securely, residents are able to access their money as they wish, records relating to personal finances were checked against money held all documentation and finances were found to be correct. Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 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 4 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 4 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 4 3 3 Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Broadway Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 21 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 Residential Home DS0000025332.V313540.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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