Inspection on 17/11/05 for Broom Lane Nursing Home

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 14/11/06

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:

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Snydale Care Home

Hawkhills

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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 Unannounced Inspection 17th November 2005 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 Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 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.V252795.R01.S.doc Version 5.0 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 Four Seasons Health Care (England) Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) Heather McGrath 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.V252795.R01.S.doc Version 5.0 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. 21st April 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 is a small garden area to the front and rear of the home and adequate car parking facilities. It is close to Rotherham town centre with good bus routes outside the home. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection in the year 2005/2006 and took place over one day the inspection commenced at 09.30 and finished at 15.00. The previous requirements were looked at with the Deputy manager. A full tour of the building took place observing the environment, staff and practices. 16 Service users, 6 staff, 7 representatives and 2 visiting professionals were spoken to. Thirteen comment cards were also received following the inspection all gave very positive feedback. The Manager has left the home this has not been notified to CSCI the Deputy Manager was overseeing the home until the new manager is able to commence employment. Four Seasons need to notify CSCI of the change in management and submit an application for the new manager to be registered with CSCI. What the service does well: What has improved since the last inspection? The care plans are much improved on all units they contain all the required information and are regularly updated to ensure the needs of the service users are met. The carpets have all been cleaned following requirements made during a complaint investigation these are now much improved giving the service users a pleasant environment to live in. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 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 Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 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.V252795.R01.S.doc Version 5.0 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): 2, 3, 4, & 5 Service users have a contract and know the home will meet their needs. EVIDENCE: The new contracts have been sent out and are gradually being returned the deputy manager was aware of the need to involve advocacy services if required when the service users were signing the contracts the new contracts will safeguard the service users. Full assessments are carried out on all perspective service users these were seen in the plans of care and were comprehensive ensuring all service users needs could be met. The home offers trial visits prior to admission this includes perspective service users relatives and friends. The trial visit could be a look round the home, stay for lunch or tea or even overnight. This ensures it is the right home for the service user. Service users and visitors spoken to all told the inspector that they had been offered trial visits and most had taken up the opportunity to ensure it was the correct choice. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 9 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 & 11. Service users health care needs are fully met and set out in the plan of care. EVIDENCE: A selection of care plans on each unit were looked at by the inspector these had greatly improved since the last inspection and set out the service users health, social and personal care needs to ensure their needs are fully met. Service users spoken to all spoke very highly of the staff and said “the staff know what our needs are and look after us very well”, “we have a laugh together and the entertainment is very good”. The feedback received showed that all service users needs are met. Risk assessments were completed in all plans of care although some could do with more detail to explain the risk fully with measures in place to reduce the risk to the service user. Death and dying is also covered in the plans of care and staff spoken to were aware of the need to treat services users and their families with sensitivity and respect at all times. The Deputy Manager explained that the home have a good relationship with the McMillan Nurses who provide training on palliative care and keep all the staff up to date to ensure that all service users needs regarding terminal care and dying are met. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 10 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. 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 however there is no supper offered and no menu available. EVIDENCE: There were two activities co-ordinators employed at Broom lane working in total 30 hours. There was a good social assessment in the plan 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. There was a programme devised with input from service users ensuring they had a choice and this was displayed on the notice board. All service users spoken to by the inspector confirmed that activities were well organised and enjoyed meeting the needs of the service users. All service users seen by the inspector praised the activities co-ordinators. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 11 The menus seen were varied, wholesome, appealing and nutritious. The lunchtime meal was observed the food was well presented, staff were pleasant and gave assistance where it was needed discretely and sensitively and the mealtime was unhurried. Three full meals are offered each day with plenty of choice, but many service users said, “Supper was never offered” this gives a large gap between meals over 12 hours. This large gap has the potential to leave some service users hungry and lacking energy. Menus were not displayed for the service users and comments received from service users stated they did not know what was for meals until they sat down they said, “It would be nice to know beforehand what was available”. The inspector was told staff used to go round and ask services users the day before what they would like to eat but this appears to have stopped. A suggestion also received from some service users was that a menu was placed on each table with the week’s choices on in order that service users could look at what food was available. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 12 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 Complaints are taken seriously and service users are protected from abuse. 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 investigated by CSCI and necessitated some requirements being made these have been complied with. Relatives and service users spoken to were aware of the complaints procedure. Many told the inspector if they had any concerns they would raise it with the staff and if this had been done in the past it had been dealt with promptly and efficiently ensuring service users are safeguarded. Service users legal rights are protected they are able to participate in the civic process if they so wish, there is also access to advocacy services for service users who lack capacity to ensure the needs of service users are met. 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.V252795.R01.S.doc Version 5.0 Page 13 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, 22, 23 & 24 Service users live in safe comfortable surroundings with the environment well maintained. EVIDENCE: The home is well maintained with a programme of routine maintenance. The carpets have all been cleaned following a visit by CSCI regarding a complaint. The home provides adequate communal space for the service users, which is well decorated and homely. There is also adequate outdoor space to meet the needs of the service users. There is a small garden area to the front and rear of the building, which is well used in summer by the service users. The dining carpet on Broom unit is badly marked and stained however this is due to be replaced to improve the environment for the service users. Service users have sufficient toilets and bathrooms in the home with rooms on the Sitwell unit all having en-suite facilities. Service users rooms observed on the day of the inspection were well decorated and maintained and personalised meting the needs of the service users. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 14 Specialist equipment was seen during the inspection for the service users to maximise their independence. There had been a small fire in the staff room caused by a cigarette still alight placed in a plastic bin all procedures were followed and staff are no longer allowed to smoke in this room. The inspector was told staff have to smoke outside however staff were observed smoking in the residents smoke room, the staff smoking policy needs to be confirmed and all staff made aware to prevent any further accidents. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 15 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 Service users needs are met by the staff on duty. EVIDENCE: The home provides staffing number adequate to meet the needs of the service users a staff rota was seen showing staffing numbers, which are mostly maintained however when staff sickness occurs additional staffing is not provided and many shifts operate with reduced staffing numbers. Agency staff have been used a lot recently on nights and this was commented on by many service users spoken to as they did not like the agency staff as they did not now how to meet their needs. The Deputy Manager explained to the inspector that the night staff team were two carers short, these had been employed but were waiting POVA clearance and CRB checks then they could commence work and the situation would be rectified and service users needs would be met. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 16 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 The homes Manager has left and has yet to be replaced. EVIDENCE: The Manager has left the home this has not been notified to CSCI the Deputy Manager was overseeing the home until the new manager is able to commence employment. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 17 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 X 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X 3 3 3 X X STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X X X X Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 13 Requirement Risk assessment must be detailed to ensure staff are aware of the risks and are able to reduce the risks to service users. The home must ensure a supper is offered to service users to prevent a large gap between tea and breakfast. Also to provide a menu to ensure service users know what choice is available at mealtimes. Ensure there are adequate staff on duty at all times to meet the needs of service users. Notify CSCI of management changes and appoint a new Manager and submit an application to CSCI to register the new manager. Timescale for action 01/02/06 2 OP15 16 01/02/06 3 4 OP27 OP31 18 8 01/02/06 01/01/06 Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations Ensure the staff smoking policy is reviewed and all staff made aware of new policy and that it is followed. Broom Lane Nursing Home DS0000003074.V252795.R01.S.doc Version 5.0 Page 20 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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