Inspection on 18/11/05 for Broomcroft House

This inspection was carried out on 18th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Broomcroft House 22/03/07

Broomcroft House 30/08/05

Broomcroft House 02/11/04

Broomcroft House 06/05/04

Similar services:

Snydale Care Home

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Larchfield Manor

Hawkhills

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 Broomcroft House Ecclesall Road South Sheffield South Yorkshire S11 9PY Lead Inspector Marina Warwicker Unannounced Inspection 18th November 2005 12.45 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 Broomcroft House DS0000021771.V263980.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. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Broomcroft House Address Ecclesall Road South Sheffield South Yorkshire S11 9PY 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) 0114 235 2352 0114 235 2351 BUPA Care Homes (AKW) Ltd Mr Martin John Lisle Deakin Care Home 87 Category(ies) of Old age, not falling within any other category registration, with number (87) of places Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Broomcroft House is situated in the suburbs of Sheffield, with the city centre being approximately four miles away. Located on the edge of Ecclesall Woods; it is on a bus route and within easy walking distance of the local shops, including the post office. This is a two storey purpose built stone building specifically to meet the needs of eighty-seven elderly people who require nursing and/or personal care. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on Friday 18 November between midday and 6pm. The inspector spoke to residents and observed lunchtime in the two dining areas. Staff were interviewed and visiting relatives were also approached to find out their views of the care delivered at the home. The inspector has written to some relatives and staff seeking their views. The outcome of the survey will be discussed with the manager of the home. This is the second statutory inspection for this year and it is important that this report should be read in conjunction with the last report to get an overview of this service. What the service does well: What has improved since the last inspection? What they could do better: The information in some parts of the care plans was not clear and the staff had not completed the records correctly. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 6 The care staff expressed their lack of training and guidance when they had been looking after service users who were dying. Service users were in the dining room waiting for lunch whilst others were almost finishing the meal. There was inconsistency in the ordering of meals by the care staff and the staff offered choices that were mot on the menus. 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. Broomcroft House DS0000021771.V263980.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 Broomcroft House DS0000021771.V263980.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 Trial visits are encouraged by the home. Prior to moving into the home all residents have their needs assessed to ensure that the home is able to cater for them. The residents or their next of kin are provided with a statement of terms and conditions following admission to the home. EVIDENCE: Three service user plans were checked and the inspector discussed the admission process with the staff. All three service users had contracts. Copies of the signed contracts were seen in the home’s files. The service users said that the manager visited them before they moved into the home to find out about their care needs. Broomcroft House DS0000021771.V263980.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): 7,8,9,10&11 The residents’ health, social and personal care needs are documented in some of the care plans. A range of health care professionals visit the home to assist in maintaining the care needs of residents. Medication procedures provided protection to residents. Residents’ privacy and dignity is maintained. The staff need specific training and guidance on how best to deal with death and dying of service users. EVIDENCE: An up to date care plan has been implemented and the inspector with the help of the charge nurse chose three care plans belonging to recently admitted residents. The care plans had been revised on the basis of the needs assessments. But the information in some parts was not clear and the staff had not completed the records correctly. For example: • An assessment of the nutritional need of a service user was checked. The primary observations for this assessment are the person’s weight and height. This was not recorded. Therefore there was no record of the service user’s body mass index. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 10 • • Skin integrity of a service user had been assessed using the tool known as Waterlow score. The calculation was incorrect. Since the score did not reflect the service user’s medical condition. Social and recreational needs of a service user had not been recorded in the care plan. The lack of information had contributed to some misunderstanding and anxiety among other service users and staff. The Medication Administration Sheets of the three service users were appropriately recorded and the qualified staff had good knowledge of the affects and side effects of the medication. Discussions took place about how best to involve the care staff in the observation of any adverse reactions or side effects of medication since the care staff spend more time with the service users. Four service users said that they were happy with the staff and the care they provided for them. A relative praised the way in which the staff conducted themselves. The care staff expressed their lack of training and experience when they had been looking after service users who were dying. They said that each nurse had their own way of caring for the dying and that they wanted universal guidance. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 The service users have the opportunity to exercise their choice in relation to routines of the day, personal and social relationships, religious observance, choice of food, frequency of meals and meal times. There was provision for leisure and social activities to stimulate the residents and give them some self-worth and independence. Meals served at the home are of a good quality and the residents are offered a choice. The residents are able to have snacks and drinks in between meals if they so wish. EVIDENCE: During lunchtime several service users were waiting for lunch to be served whilst the others had finished the meal. On questioning, the service users said that often they had to wait since not enough meals were sent up from the kitchen. The inspector ascertained that there was inconsistency in the ordering of meals by the care staff and the staff offered choices that were not on the menus. This was partially rectified on the day with the help of the nurse in charge and the administrator. A print out of the choices at each mealtime was circulated to staff for completion for the following two days. Staff were instructed that if service users wanted food that was not on the menu the cook must be informed. Broomcroft House DS0000021771.V263980.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 The management investigate complaints in an impartial manner and avoid blame culture. This helps staff and service users to raise any concerns or complaints however small they may seem. The residents are enabled by the staff to exercise their legal rights and for those who lack capacity, an advocate service is offered. Such arrangements help residents to receive independent advice and help. The home has a complaints policy The management gives opportunities for staff to attend courses on adult protection and allegation of abuse. This is to protect service users and staff. EVIDENCE: Some staff have attended training on adult protection and there is an ongoing programme to train all staff. The manager and the deputy were off duty on the day of inspection therefore the inspector did not ask to see the records of complaints. This will be done at the next inspection. Broomcroft House DS0000021771.V263980.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): 22 The above standards were checked during the last inspection. EVIDENCE: The home was clean and the staff followed good hygiene procedures. The service users and relatives said that Broomcroft was a comfortable home. The staff said that they require more correct size slings to use with the new hoist. Some staff requested the purchase of more hoists due to the dependency levels of service users. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 14 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 & 29 Broomcroft has a thorough recruitment procedure to protect the service users and the staff at the home. The staff numbers and skill mix of qualified nurses and health care support workers are allocated so that the service users are able to receive appropriate care. EVIDENCE: The CSCI was recently informed of a concern regarding inappropriate placement of a service user. This service user needed staff supervision and familiarisation of the new environment. The inspector discussed this situation with the Responsible Individual who arranged additional staff to be on duty. Four staff files were checked. The information held in the staff files has improved. However, the management needs to check the full employment history, which needs to include the dates and months of each employment. All gaps needed to be explored. Not all files had photographs of the staff. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 15 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&36 The manager and her team ensure that their approach creates an open and positive atmosphere at the home. Systems are in place to supervise staff at regular intervals. EVIDENCE: The staff were very positive about the manager. The service users and the relatives knew who the manager was and that they have opportunities to meet with her. The manager is in the process of being registered with the CSCI. The inspector checked the service users’ moneys. These were appropriately recorded and accounts maintained by the administrator. Care staff and nurses need to receive formal supervision at least six times a year. Some care staff did not understand the purpose of supervision. All records requested for inspection were safely kept at the home. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 16 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 2 3 3 3 2 X X 3 3 STAFFING Standard No Score 27 2 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 3 2 3 X Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 17 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 2 Standard OP7 OP8 Regulation 15,13 14,17,13 Requirement Information in the care plans must be correct and accurate. When assessing the health needs of service users, the staff must ensure that assessment tools are used correctly and appropriate information is documented in the care plans of individuals. All care staff must receive guidance and training on dealing with death and dying of service users. The staff must make sure that service users are offered the choices on the menu. If residents request further choices the cook must be involved. Immediate. All concerns and complaints must be investigated and complainents must be kept up to date with developments. All staff must receive training on Identifying abuse and adult protection. They must be familiar with the policies and procedures relating to these. The management must provide in numbers appropriate sizes of slings for the use of service DS0000021771.V263980.R01.S.doc Timescale for action 16/12/05 16/12/05 3 OP11 12,15 27/01/06 4 OP15 16 18/11/05 5 OP16 22,17 27/01/06 6 OP18 12,17 06/12/05 7 OP22 16,23 27/01/06 Broomcroft House Version 5.0 Page 18 8 OP27 18 9 OP29 12,19 10 OP31 9 11 OP36 18 users. When a service user needs additional support the manager must allocate competent staff to care for the service user. Immediate. All gaps in employment histories must be explored and the manager must be satisfied with the explanations. Immediate. All staff must have an up to date photograph as part of their identification. The manager must be registered with the CSCI. The manager must have a recognisable management qualification. All care staff must receive supervision at least six times a year and written records of the supervision must be kept at the home. 06/12/05 06/12/05 06/12/05 06/12/05 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 OP22 OP9 Good Practice Recommendations The management should review the moving and handling equipment within the home to reflect the present needs of the residents. Information on medication should be accessible to care staff so that they are able to observe and report, if a service user suffers any ill effects. Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Broomcroft House DS0000021771.V263980.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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