Inspection on 14/11/06 for Broom Lane Nursing Home

This inspection was carried out on 14th November 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.

Other inspections for this house

Broom Lane Nursing Home 17/11/05

Broom Lane Nursing Home 21/04/05

Broom Lane Nursing Home 08/12/04

Broom Lane Nursing Home 06/07/04

Broom Lane Nursing Home 03/11/03

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Broom Lane Nursing Home 174 Broom Lane Rotherham South Yorkshire S60 3NW Lead Inspector Sarah Powell Key Unannounced Inspection 14th November 2006 09:10 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 Broom Lane Nursing Home DS0000003074.V312159.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. Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broom Lane Nursing Home Address 174 Broom Lane Rotherham South Yorkshire S60 3NW 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 541333 01709 700850 broom.lane@fshc.co.uk www.fshc.co.uk Four Seasons Health Care (England) Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Pat Potter Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61) of places Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide eight Intermediate Care beds in The Broom Unit is granted as a condition of registration. 17th November 2005 Date of last inspection Brief Description of the Service: Broom lane provides nursing and personal care for service users over the age of 65, it also has 8 beds for intermediate care. All the rooms are single with some being en-suite. The home is in two units Broom and Sitwell, which are connected by a corridor. Nursing care is provided in the Broom building. There are small garden areas to the front and rear of the home and adequate car parking facilities. The home has a statement of purpose and service users guide which are available to service users and perspective service users and their families these give information about Broom Lane and what service is provided. The fees at Broom Lane range from £340 to £480 with free nursing care fees in addition to this. Toiletries, hairdressing, chiropody and some transport costs for outings are extra. Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection in the year 2006/07 it was unannounced and took place over one day on 14th November 2006 at 09.10 and finished at 17.00. As part of the inspection process the inspector spoke to 11 residents, 3 visitors, 1 visiting professional, 6 staff and the Manager. A partial tour of the building took place, observing environmental standards, staff and practices. A number of records were examined these included medication, three service users care plans, menus, staff rotas, recruitment, training and quality assurance systems. Four surveys were returned to the inspector completed by the service users and many comments were very positive. Feedback was given to the Manager when the visit was completed. What the service does well: What has improved since the last inspection? What they could do better: The environmental standards within the home had deteriorated with many areas needing attention; redecoration and new carpets are required to ensure a clean well maintained environment is provided for the service users. Broom Lane Nursing Home DS0000003074.V312159.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. Broom Lane Nursing Home DS0000003074.V312159.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 Broom Lane Nursing Home DS0000003074.V312159.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 & 6. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All service users needs had been assessed. The intermediate care unit was very good it helped to maximise service users independence and enabled them to return home. EVIDENCE: Three service users were case tracked as part of the inspection process and the assessments seen in these care plans were fully completed, comprehensive and identified all the service users needs. Service user who had been referred through the care management arrangements had copies of social services assessments in the plans of care. Dedicated accommodation was provided for the intermediate care. There was a dedicated staff team with a unit manager. Specialist facilities and equipment was seen provided for the unit. A physiotherapist seen commented that the Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 9 unit was very good, staff delivered short-term intensive rehabilitation and were enabling service users to return home. Records seen on the unit confirmed that the majority of service users admitted for intermediate care were rehabilitated and sent home and only a few following full assessments are admitted for long term care. Service users spoken to on this unit were full of praise for the staff and services. Staff receive appropriate training to be able to meet the needs of the service users on the intermediate unit. Records were seen and staff confirmed they received training and if they found some additional training they felt was appropriate they were usually encouraged to attend. Broom Lane Nursing Home DS0000003074.V312159.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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All health and personal care needs of service users were met. EVIDENCE: Three plans of care were looked at during the inspection and a comprehensive plan was in place. The plan set out in detail the action, which needed to be taken by care staff to ensure all aspects of the health, personal and social care needs of the service users were met. The manager and staff promoted service users health and maintained access to all health care services to ensure their needs were met. Details of the services accessed were clearly recorded in the plans of care. Staff spoken to talked about service users in a sensitive and respectful way and understood the need to promote their dignity. Staff observed during the day treated service users and visitors with respect. Service users who were spoken to told the inspector “the staff look after us very well and are always polite and respect our wishes”. Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 11 The home has changed suppliers for the medication since the last visit and the systems to safeguard service users had improved. Records were seen for all medication received, administered and disposed of. The home had the appropriate systems in place for disposal of medication and had a contract with a waste disposal company. Broom Lane Nursing Home DS0000003074.V312159.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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users maintain community contact and have their social, cultural and recreational interests met and are able to exercise their choice. Meals are appealing and balanced EVIDENCE: There were two activity co-ordinators employed at Broom lane working in total 30 hours. There were good social assessments in the plans of care for each service user detailing their likes and dislikes. The activities organised were varied and were arranged either as a group or individually. Activities also maintained contact with the local community to meet the needs of service users, although service users commented that there had not been as many outing this year as usual and they had missed them. The menus seen were varied, wholesome, appealing and nutritious and service users told the inspector that supper was now offered each night to ensure there was not a large gap between meals. Service users told the inspector that Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 13 the food was very good and there was always a choice, meeting the needs of all service users. Broom Lane Nursing Home DS0000003074.V312159.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 & 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has robust systems in place to protect service users. EVIDENCE: The home has a comprehensive complaints procedure, which states timescales to be followed and contact details of home, head office and CSCI. One complaint has recently been received by CSCI and was investigated during the visit the issues were not substantiated, however one issue raised stated that the home was short staffed, this was partly upheld as the home had been working short staffed on some occasions due to staff shortages, sickness and maternity leave. The manager is actively recruiting to resolve these issues. The home had also received 3 concerns from relatives these were all well documented and fully investigated to ensure service users and staff are protected. The home has a good adult protection policy and all staff have received training and all staff have POVA and CRB checks prior to appointment in order to protect service users. Broom Lane Nursing Home DS0000003074.V312159.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 & 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home requires some refurbishment to ensure standards are maintained at a good level. EVIDENCE: A tour of the building took place during the visit and many rooms required some improvement in particular the two lounges and entrance hall, the carpets were very stained and encrusted in dirt, which was impossible to get clean. The wallpaper was damaged and marked and needs replacing. The toilet and bathroom floors were all marked and stained and need replacing the floor covering in the walk in shower was not properly adhered to the floor and could be a tripping hazard. Some bedrooms had a foul odour and needed new floor coverings. The environment needs to be improved to ensure the service users live in a well maintained home. Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 16 A programme of maintenance and renewal needs to be drawn up with clear timescales when work is to be carried out, it would be beneficial if the manager carried out a full building audit prior to this. Many service users and relatives commented on the poor décor, that it could do with being redecorated and new carpets fitted. A new floor covering has been provided in the dining rooms since the last inspection, which has much, improved these areas for the service users. The grounds were tidy, safe and attractive although the grass was very long, the manager told the inspector that they had not had a maintenance person for some time due to long term sickness so had been using contractors for the grass and it had not been cut as often as it should have been. The premises were kept clean the carpets were impossible to thoroughly clean due to the engrained in dirt; carpets were cleaned regularly but needed replacing. The laundry was small the staff told the inspector the home could do with another dryer but there was not enough space to provide this. Clothes were hanging in the corridor due to space shortages these need to be removed from the corridor and a proper storage place identified. Clothes were clean, pressed and clearly identified whom they belonged to ensuring service users needs are met by providing clean well presented clothes. Broom Lane Nursing Home DS0000003074.V312159.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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Suitably qualified staff and robust recruitment procedures meet services users needs. EVIDENCE: The home provides staffing number adequate to meet the needs of the service users a staff rota was seen showing staffing number. The home was short staffed at the time of the visit due to maternity leave and sickness, staff cover shifts when they are able to ensure service users needs are met but occasionally this is not possible and the shift runs short. The manager is actively recruiting to ensure this is rectified. The home has a new deputy manager, which has improved things the service users commented that the deputy was lovely, had fitted in really well and was very approachable. A selection of staffs training files were seen records were good and all training had been carried out to ensure service users needs are met. Moving and handling training was due for renewal for a few staff. To ensure this is addressed the home had a staff member on the trainers course, which will be completed on 1st December, and then the training will be updated to ensure all staff are properly trained. The home has 50 of care staff trained to NVQ level 2 or above this has decreased with staff leaving and maternity leave, however the home has a Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 18 rolling programme and staff are currently undertaking the course to ensure service users are in safe hands at all times. A selection of personal files were looked at they all contained all the required information and checks to ensure the service users are protected. Broom Lane Nursing Home DS0000003074.V312159.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, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Management and administration of the home promotes the well being of service users. EVIDENCE: The home has appointed a manager since the last visit and she has successfully been registered with CSCI. The manager is suitably qualified and experienced to run the home and has registered on the registered managers award. The home has good quality monitoring systems in place the audits on the Broom Unit had lapsed due to no deputy in post this has now been resolved and the audits have recommenced to ensure the quality is maintained, as part Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 20 of this the manager intends to carry out a full environmental audit to identify areas which need improvement. Service users finances were looked at in detail at the last visit the administrator assured the inspector that no procedures had changed and all finances were in order to ensure service users were safeguarded. Safe working practices are maintained within the home with good health and safety policies and procedures, all maintenance records were seen and up to date. During the tour of the building trailing cables were found in a bedroom, this was shown to the manager who immediately rectified the situation by rearranging the layout of the room. The manager also requested an additional plug socked be installed to prevent it happening again and meet health and safety requirements protecting staff and service users. All environmental risk assessments were completed and clearly documented to ensure staff and service users are protected. The water temperatures had not been checked since the maintenance person had been on sick leave this was discussed with the manager and she agreed to nominate a person to carry out these checks until a new person is in post. Broom Lane Nursing Home DS0000003074.V312159.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 X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 23(2)(d) Requirement Communal carpets must be kept maintained and cleaned in particular the lounge carpet on Broom. (Old timescales 1.12.05 & 01/04/06) Timescale for action 01/01/07 2. OP19 23 3. 4. OP26 OP38 13 13 The home must be maintained in 01/11/07 a good state of repair internally in particular floor coverings in the lounges, bathroom, toilets corridors and the décor throughout the home. The registered manager must draw up a programme of maintenance and renewal with clear timescales when work is to be completed prioritising the most urgent. The programme must be completed by 1.1.07 and forwarded to the inspector and all the identified work completed in the next 12 months. The clothing stored outside the 01/01/07 laundry must be removed and alternative storage found. The registered manager must re- 01/12/06 commence taking the water temperatures and recording the findings. DS0000003074.V312159.R01.S.doc Version 5.2 Page 23 Broom Lane Nursing Home 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 Broom Lane Nursing Home DS0000003074.V312159.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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