CARE HOME ADULTS 18-65
Broom Haven 1a Broom Grove Rotherham South Yorkshire Lead Inspector
Valerie Hoyle Unannounced Inspection 26th January 2006 12:00 Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Broom Haven Address 1a Broom Grove Rotherham South Yorkshire 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) 01709 821418 gail@tipple9039.fsnet.co.uk John Tipple John Tipple Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Broom Haven is registered for three younger adults with learning difficulties who mainly communicate using Makaton. Staffing levels are sufficient to ensure service users can be supported to pursue life skills and leisure activities. The property is a modern four bedroom detached bungalow in a residential part of Rotherham. It has three single bedrooms, a large diner, a domestic kitchen, bathing facilities and a staff sleeping in room. There are lawns to the front and side of the house. The area is enclosed and has an outdoor seating area for the service users. The home is close to local amenities and a short walk or bus ride in to the town centre of Rotherham Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second unannounced inspection of this inspection year. (2005/06) This unannounced inspection was conducted over 3.5 hours where a partial tour of the building was undertaken. The inspector examined three service users care plans and supporting documentation. Three staff members and one service user were spoken to during the visit. Staff was observed interacting with the service user in a positive supportive manner, enabling her/him to participate in daily living skills. The registered manager was not available during this visit. What the service does well: What has improved since the last inspection?
The registered provider continues to improve the environment by decorating areas as required, the dining /lounge has recently been decorated. Service users are encouraged to participate in choosing colour schemes for their own bedrooms. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed at this inspection. EVIDENCE: There have been no new admissions of service users in Broomhaven since the previous inspection. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The home clearly promotes philosophies to enable residents to meet their full potential, with clear care plan instructions and comprehensive risk assessments to maximise their safety and protection. EVIDENCE: The registered manager operates ‘Person Centred Plans’ for two of the service users who attend training centres. These are formally reviewed every four months. The reviews may take place either at the home or at the day centre and are used to coordinate activities at the centre and aims and dreams within the home setting. There is also a comprehensive individual plan for each service user, that is user friendly. They are well written with a daily entry made recording any significant events. These plans describe in detail the intervention required to meet their needs. Regular house meetings are held to discuss issues relating to the running of the home and to agree activities.
Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 10 One service user is able to manage his/her own finances and the manager acts as appointee for the other two service users. Documentation supporting the financial arrangements was examined and was found to be accurate. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 15 Social and leisure activities are provided at the home for service users, to maintain and develop independent living skills, supported by an informed staff group. Service users are helped to maintain links with family members, with weekend and evening visits, as agreed in their care plans. EVIDENCE: Service users are encouraged and supported to maintain links with the local community and two regularly attend a local group at ‘the meeting place’ organised by Mencap. Two service users have booked a summer vacation, organised and staffed by Mencap. Service users also have opportunities to have holidays with their family. Two service users continue to attend local training centres during the week, and the home has information about the activities for each day they attend. Staff support service users to pursue leisure interests including gardening and playing computer games. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 12 Service users are encouraged and supported to undertake routine tasks around the home including preparing vegetables and washing the pots. Service users are also encouraged and to tidy their own bedrooms and change their own beds. Service users are encouraged and supported to maintain links with family members and spend time visiting either with support from staff or independently. All service users spent time away visiting family over the Christmas period. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 Staff provides sensitive personal support to ensure privacy dignity and independence is maintained for all service users. Medication policies and procedures are well managed and staff have the necessary skills to administer the medication to service users, ensuring the safety and protection of service users. EVIDENCE: Service users are generally independent with regard to their personal care, although staff provide support where needed with health care issues arranging appointments and escorting to doctors appointments. The registered manager should consider developing a health care plan for the service users as discussed with the care manager. An audit of medication stocks and records was examined and were found to be correct. Staff have received accredited medication training provided by a local college, to ensure they have the necessary skills and knowledge to undertake this task. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Service users are provided with information to enable them to raise concerns about the home and their care. Adult Abuse Policies and procedures and training of staff on abuse ensure the protection of service users from abuse EVIDENCE: The home has a complaints procedure that is available to service users and visitors that is kept in the home. The procedure is also referred to in the service users guide, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure. The registered manager has a copy of the Local Authorities Adult Protection procedures. They also have an Abuse Policy, which has been prepared by the owners and is incorporated into the homes policy and procedure manual. The registered manager reiterates the procedures at staff meetings and supervision and staff-training files also confirms that they have attended training in adult protection. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The home provides a well-maintained safe environment suitable for service users. The home provides a clean and hygienic environment to maintain the health and safety of service users. EVIDENCE: A partial tour of the building found it clean and free from odours. The home provides comfortable communal areas with a lounges/dining area and a domestic kitchen. The grounds were tidy, and accessible to the service users; appropriate seating is available for service users. The home is close to all local amenities, and service users are able to walk to Rotherham town centre. Individual bedrooms are personalised to service users own interests and hobbies and are furnished appropriately including music centres and televisions. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Staff have the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the service users. Recruitment policies are followed ensuring the safety and protection of service users. EVIDENCE: Staff are organised to ensure there are sufficient to meet the needs of service users who spend their time at the home during the day. Staff have the necessary skills and have achieved awards in care. Staff have worked at the home for a good length of time and have good relationships with the service users. Staff spoken to said they enjoyed working at the home, and felt part of a team who support service users who live at Broomhaven. Examination of staff training files has indicated that staff have not yet received any formal training to deal with challenging behaviour, therefore staff must attend a behaviour management course to ensure they have the necessary skills to deal appropriately with service users. Refresher training is also required in areas of food hygiene and the protection of vulnerable adults. A number of staff recruitment files were examined, and there is evidence that all the required employment checks have been undertaken prior to
Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 17 commencing work at the home, ensuring the safety and protection of service users. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home is well managed to ensure the safety and protection of the service users. The registered provider is unable to demonstrate that he actively seeks the views of service users. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment EVIDENCE: The registered manager, who is also the owner of the home, has considerable experience and knowledge of younger adults with learning difficulties. The registered manager has now completed the registered managers award, although the inspector was not able to examine the certificate to confirm this information. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 19 The registered providers hold regular house meeting with the three service users to gain their views, although communication is sometimes difficult due to their ability. The registered providers should develop a quality assurance system that demonstrates satisfaction levels, this should include surveys for relatives and others involved in the care of service users. The registered manager has the required Health and Safety policies and procedures and maintenance and service records examined were up to date and current to the services provided. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 3 X X 3 X Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 21 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 YA35 Regulation 18 Requirement The registered provider must ensure the staff have the necessary knowledge and skills in behaviour management (Timescale 1 Dec 05 not met) The registered manager must ensure staff receive training in the protection of vulnerable adults and food hygiene. Timescale for action 01/04/06 2. YA35 18 01/06/06 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. 2. Refer to Standard YA19 YA39 Good Practice Recommendations The registered manager should develop healthcare plans for all service users. The registered providers should develop quality assurance systems to gain the views of service users and other stakeholders. Broom Haven DS0000003127.V277050.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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