Inspection on 01/11/06 for Broome End Care Centre

This inspection was carried out on 1st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Broome End Care Centre 06/05/09

Broome End Care Centre 13/05/08

Broome End Care Centre 14/05/07

Broome End Care Centre 28/11/05

Broome End Care Centre 11/05/05

Broome End Care Centre 26/01/05

Broome End Care Centre 10/06/04

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

CARE HOMES FOR OLDER PEOPLE Broome End Care Centre Pines Hill Stansted Mountfitchet Essex CM24 8EX Lead Inspector A Thompson Unannounced Inspection 1st November 2006 11:30 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 Broome End Care Centre DS0000017785.V318440.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. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broome End Care Centre Address Pines Hill Stansted Mountfitchet Essex CM24 8EX 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) 01279 816455 01269 814598 Ashbourne Homes Limited Position Vacant Care Home 37 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (37) of places Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 37 persons) Persons of either sex, over the age of 65 years, who require care by reason of dementia (not to exceed 9 persons) The total number of service users accommodated in the home must not exceed 37 persons 28th November 2005 Date of last inspection Brief Description of the Service: Broome End is a large detached house, set in spacious grounds on the edge of the village of Stansted Mountfitchet. The home is registered to provide residential care to 37 older people (over the age of 65), with varying degrees of dependency, including nine places for people with diagnosed dementia. Residents are accommodated in twenty nine single rooms and four double rooms, with communal space comprising three lounges and two dining rooms. Accommodation is provided on all three floors of the home and there are two passenger lifts to enable access to all areas. Broome End is equipped with facilities, aids and adaptations to enable staff to deliver quality care. The gardens and grounds are at the rear of the home and ramps provide access. Unfortunately at the time of this inspection all garden areas were out of bounds to residents due to subsidence and resulting hazards. Ample off road car parking is provided to the front for visitors, and bus services pass the building along the main road. Local shopping facilities are a short walk away. Information from the home states that weekly fees range from £437 to £624. Past inspection reports are available from the home, and from the CSCI internet website. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Wednesday 1st November 2006, with a second announced visit taking place on 15th November to complete the process. The content of this report reflects the inspector’s findings on the day/s of the inspection along with information provided by the service and feedback by service users, relatives, staff and other parties. Practice, procedures and the views of service users received after this inspection will be reported on in future inspection reports. Discussions took place with nine service users, the manager, area manager, administrator, chef, three members of staff and three visitors. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. Generally the residents spoken to expressed satisfaction with the care they received and with the quality of the food and accommodation offered, however some were reluctant to speak openly. The manager was made aware of this fact, and agreed to reassure and encourage residents to make their views on the day to day service they received known to management, and to CSCI. Questionnaires were left at the home so that residents and relatives had the opportunity to make their views known to the Commission, anonymously if preferred. Staff confirmed they received support from management. They also confirmed that they had been offered NVQ training. Twenty-eight standards were inspected with twenty-three met and five almost met. What the service does well: The residents living in Broome End benefited from an established and experienced staff team, who displayed knowledge of the needs of individuals in their care. The atmosphere in the home was friendly and relaxed. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The subsidence in the garden needs to be fully addressed, with areas safe to access. Testing was overdue of the home’s gas appliances supply (12 month timescale). Records of daily activities offered to residents need to be completed, and available for inspection. 50 of care staff should be trained to NVQ 2 level or equivalent. Some corridors areas would benefit from redecoration. ------------------------ 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. The summary of this inspection report can be made available in other formats on request. Broome End Care Centre DS0000017785.V318440.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 Broome End Care Centre DS0000017785.V318440.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home’s assessment format and process ensured that initial perceived needs were identified upon admission. EVIDENCE: The general manager or care manager visits prospective new residents to undertake an assessment of need. Evidence of this process was seen in care plan files for residents admitted since the last inspection. Assessment headings covered included: personal care, communication, mobility, personal hygiene, diet, vision, hearing, continence, behaviour, manual handling, sleep, medication, foot & oral care, falls, social & risks. In addition there may be a Social Services assessment on file which supplements the home’s process. A care plan is compiled after admission, this will involve service users and appropriate relatives. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 9 Broome End Care Centre DS0000017785.V318440.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. 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 using available evidence including a visit to this service. The health, personal and social care needs of residents were adequately detailed in individual plans of care. Health care needs of residents were met and residents felt they were treated with respect. EVIDENCE: Four care plans were inspected. The format used was a very comprehensive document and included background information, personal details, and next of kin contacts. The residents’ needs/action sheet included the ‘aim of care’ taking account of the headings assessed when carrying out the initial assessment, and further sections added after admission. These were a physical & social assessment, a social profile, pressure care risks and a dependency assessment. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 11 Care plans seen also included comprehensive risk assessment formats, records of residents’ weight, medical consultations, had been regularly reviewed and included review and evaluation record sheets. District Nursing services support the home in pressure sore assessment and will also supply appropriate aids and treatment. Continence issues are supported by the community continence nurse and hearing needs are provided for by GP referral to a local hospital. A dentist visits the home, as does a chiropodist and an optician. The GP holds a weekly surgery in the home and will visit at other times on request. The homes medication policies and procedures covered ordering, receipt, storage, administration, homely remedies, self medicating and returns of unused stocks. Staff training on medication issues had been provided by the pharmacist on 9/10/06. Certificates of attendance to confirm this had not been issued, however staff spoken with confirmed they had received training on the system used. Documentary evidence of this training will be assessed at the next visit. Medication administration records were inspected some gaps were noted, the manager undertook to reinforce to staff the importance of fully completed records. The manager also advised that she would be improving the in-house guidance and support to staff on medication side effects and reasons for specific medication being prescribed. Progress on this will be assessed at the next inspection. Discussions with individual residents indicated that most felt they were treated with respect by staff, as did observation of staff going about their duties and interactions with residents. However as mentioned previously, some residents were unwilling to speak openly. CSCI survey forms were provided to these people. Staff on duty were seen to be courteous and caring in their dealings with residents, and most residents spoken with said staff were helpful and considerate. One observation of concern to the inspector was two residents in a lounge left sitting in their wheelchairs. This issue was discussed with the manager, who undertook to ensure that residents were always asked by staff whether they wished to be moved into a sitting room chair. If residents do choose to remain in their wheelchairs then pressure care issues must be addressed, with appropriate pressure relieving aids supplied. Survey forms were also provided for relatives and visitors to make their views known. Treatments and consultations are provided in private, residents confirmed that they wear their own clothes and that staff use their preferred term of address. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 12 Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 13 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. 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 using available evidence including a visit to this service. The lifestyle experienced within the home matched the expectations of residents. They were able to maintain contact with family, friends and participate in the local community. Residents were offered a varied, appealing balanced diet and were supported to exercise choice in their daily lives. EVIDENCE: The new manager had held a residents meeting in October, minutes of issues discussed and decisions made were seen. Further meetings were planned at six weekly intervals. Also seen were minutes of a meeting that had taken place for relatives, fourteen had attended. The home had a weekly activities programme, which was displayed around the home. Included sessions were: reminiscence, music & sing-a-longs, films, reading, cream teas and indoor exercise Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 14 The home had a post for activities coordinator but this was vacant and care staff were having to undertake this role. The new manager was recruiting into the vacant post. There were no records of the actual activities taken part in by individual residents. This is a shortfall and should be addressed. Community visitors to the home include a church minister who holds a fortnightly communion service, a priest visits fortnightly, a weekly ‘pat the dog’, a hairdresser (who also stages line dancing sessions), a library, a clothes shop and 3 monthly visits by entertainers. Daily activities and interests should be varied and meet the needs and expectations of residents, including those with diagnosed dementia. There is a recommendation in this report that the designated activities coordinator receives training appropriate to this role. Residents spoken with confirmed they were satisfied with the choices and options made available to them regarding daily routines and leisure interests on offer. Visitors spoken with said they were made welcome by staff. Some personal allowance monies are held for safekeeping and records of transactions and receipts are kept. The administrator advised that the home does not act as appointee for any of the residents. Information was displayed for residents and relatives on how to contact an independent advocate. Inspection of private rooms confirmed that residents had been permitted to bring their own personal items with them on admission. There was also confirmation of this direct from residents, who told the inspector of the furniture and personal items they had been permitted to bring in with them. Nutrition records and menus evidenced choice and variety. The main daily meal is lunch with two choices, there is also a choice at tea. Cooked breakfasts are menued twice weekly and supper snacks are available each evening. All residents spoken with said they got enough to eat and seven said it was good, and that there was always a choice, however two others said they did not always enjoy the food, but they would not specify why. Since the last inspection catering provision has moved away from being provided by contractors to the full control of the management team. Meals may be taken in private rooms or communal lounges if preferred, evidence of this practice taking place was seen. Minutes of residents meetings were seen to include discussion on meals. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 15 Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Residents knew how to complaint and the home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. EVIDENCE: The home’s complaints procedure contains guidance on how to make a complaint and who to complain to. Also included were timescales for responses from the home. Evidence was seen to confirm that records are maintained in the home, of complaints received and of any investigation and resulting outcomes. Residents spoken with said they knew who to speak to in the home if they any concerns. There had been two complaints since the last inspection. One had been resolved and the second was on-going. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 17 There was an in-house trainer on adult protection matters who has provided training to staff. This included clarifying types of abuse, recognising signs and required actions if abuse suspected. Staff spoken with displayed awareness of this subject and procedure. The homes policy on adult protection was inspected, there was written guidance for staff on recognising and reporting abuse and action to be taken by staff and the person in charge if abuse is suspected. The home was provided (by CSCI) a copy of the latest POVA guidelines. Already on site were the Essex Vulnerable Adults Protection Committee guidance booklets on abuse, which the care manager said are provided to all staff. Induction and NVQ training also includes adult protection issues. The home also had a ‘whistle blowing’ policy which provided guidance to staff on their responsibilities to report any concerns to management. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Furnishings in the home looked comfortable but not all areas of the premises seen were sufficiently well maintained. The grounds needed attention to ensure residents and staff safety was best ensured. Private accommodation was comfortable and suited to needs and preferences. The home was considered to be hygienic. EVIDENCE: The home was fully accessible to residents accommodated. Generally the home was well maintained but some corridor doors and walls had areas of chipped/bare paintwork. The new manager advised that this was due to be attended too but until progressed this report includes a recommendation on this issue. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 19 The rear garden and grounds had suffered from subsidence which, due to assessed danger, had resulted in management declaring these areas as out of bounds to residents, visitors and staff. The registered provider has taken action to identify the cause and the remedial works necessary to make the area safe for reuse. However this issue appears to have had been on-going for over three months and requires urgent attention. This report contains a statutory requirement on this matter. Private and communal accommodation and facilities were of good quality and mainly domestic in character, and suited to the needs of residents. Twenty one private bedrooms benefit from en-suite facilities. Communal wcs are located in the bathrooms and around the home. Staff call systems were located in all private rooms and communal rooms seen. The home is equipped with two shaft passenger lifts to provide access between floors. Private rooms were well decorated, comfortable and evidenced individual taste. During discussion with residents all said their rooms were comfortable. Door locks and keys are provided according to individual choice and risk assessment. All rooms seen were naturally ventilated with windows and all were centrally heated. There were four bathrooms, and one shower room in the home, baths are quipped with fixed or portable hoists. Hot water supply in the home is regularly tested by staff, records of this were seen. All radiators in the home that were seen were guarded, and lighting in residents’ rooms was considered domestic in character and fully appropriate for individuals requirements/needs. On the day of the inspection the premises were considered to be clean and hygienic. Policies and procedures were available for inspection confirming that working practices are in place to control the spread of infection. The laundry room were inspected and were equipped an appropriate washing machines (with sluice cycle programme) and tumble drier. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 20 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. 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 using available evidence including a visit to this service. Staffing levels appeared to meet the needs of residents. Staff had been provided in-house training opportunities to equip them with the skills for their role, although further NVQ training should take place. Staff recruitment procedures aimed at the protection of residents had been followed. EVIDENCE: The home’s staffing rota was inspected and confirmed that staffing levels are being maintained at six care staff on duty on morning shifts and five afternoon shifts. Night staffing is three on waking duties. The manager post is sumernumery. Separate and additional rostered staff were employed to undertake care manager, catering, kitchen assistant, administrative, activities, housekeeper, domestic and maintenance duties. Discussion with staff and records confirmed that regular staff meetings are held. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 21 Staff records and discussion with staff evidenced that application forms had been completed, interviews held, written references obtained, written terms & conditions issued and criminal records checks undertaken. Copies of proof of ID and photographs were also on file. The manager reported that five staff had NVQ 2, evidence of pass certificates were seen. Two staff were undertaking this award and a further fourteen had signed up to start this award. NMS states that 50 of care staff should have this award or equillivant, this figure is not met and therefore this reports includes a recommendation on this issue. New staff undergo the home’s induction programme. Records of this were seen, and staff spoken with who had employed since the last inspection confirmed they had received induction training. The induction package had been expanded and included modules on the principles of care, resident care, role of the worker, health & safety, effects of the setting on service provision and safety. At the next inspection records will be checked to ensure that this package is used for all new employees. The home had access to company qualified in-house trainers on: food hygiene, manual handling, health & safety, fire awareness and POVA. Training records and discussion with staff confirmed that staff had been provided training on all these subjects by the manager. On 7/11/06 ten staff were provided training on first aid by a trainer from outside the home. Evidence of pass certificates were seen and staff confirmed they had received this training. Other external training provided had included NVQ, continence, dementia and medication. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures for gaining the views of residents and relatives were in place and had been implemented. Records required by regulation were in place. Financial practices in the home appeared to have been competently managed. The health and safety of residents and staff could not be assured until the grounds are made safe, and testing of the gas supply has been completed. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 23 EVIDENCE: There was a new manager in post (since September 2006), who was in the process of applying to the Commission for registration. Her experience spans at least 8 years previously as a manager, with evidenced qualifications including: registered nurse, registered manager award, business management, skills for business and a variety of short course training appropriate to the role of registered manager. The registered provider ensures that their home managers receive regular close support and guidance from senior managers within the organisation. This includes systems and quality assurance monitoring assessments on a monthly basis. These also take account of the views of service users. There are six monthly in-house reviews of service for each individual resident. These include relatives, where appropriate. Notes were seen of meetings and decisions and included the care provided, food and accommodation. A separate quality assurance form entitled ‘The Views of Our Service Users’ is sent out annually. The form had questions on environment, health & wellbeing, daily life, suggestions & complaints, privacy & security. An overview of the comments and replies is included on each form. Evidence of timescales and action on responses for this process will be assessed at the next inspection. Some residents personal allowance monies were held for safe keeping by the home. Records of transactions, receipts and balances held were kept and were inspected with no errors noted. The new manager had commenced 1-1 formal staff supervision sessions. Evidence of this was seen and staff spoken with also confirmed this process had commenced. The format used included an overview and principles of good supervision with recorded notes on content, items taken forward and any tasks to be carried out. Random samples of records required to be kept were inspected. These included: complaints, assessments, care plans, staff rotas, staff recruitment, accident records, visitors book, fire drills, regulation 37 notices, regulation 26 reports, menus, medication, background info’ and next of kin details, cash held for safekeeping and fire procedures. All seen were satisfactory. Discussions with staff, management and inspection of records confirmed that training is provided to staff in moving and handling, fire safety, food hygiene, first aid and basic training in infection control. Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 24 Certificates and service records were available for inspection to confirm that the home’s fire equipment, passenger lift, hoists, call alarms, emergency lights and portable electrical appliances had all been tested/serviced within recommended timescales. The electrical installation supply had been retested in November but no evidence of this was available, and the home’s gas supply retesting was overdue. This report includes statutory requirements on these shortfalls. The home had COSHH data sheets for cleaning substances used. There were premises risk assessments in place. The grounds needed attention with regard health & safety of residents and staff (please refer to NMS 19). Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 25 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 X 3 X 3 X 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 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 3 2 Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13 Requirement The registered provider must provide evidence to the Commission that retesting of the home’s electrical installation supply had taken place in November 2006. The registered provider must ensure that retesting of the home’s gas supply is carried out (12 month timescale applies), with records available for inspection. The registered provider must ensure that the gardens/grounds are safe to access. Timescale for action 30/11/06 2. OP38 13 31/12/06 3. OP38 OP19 23(2)(o) 31/12/06 Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 27 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 OP12 OP19 Good Practice Recommendations The manager should ensure that records are kept of daily activities offered/taken part in by residents. The registered provider should ensure that redecoration/repairs are made to doors and walls in corridors in the home. The registered provider should ensure that 50 of care staff are qualified to NVQ level 2 award or equivalent. The registered provider should ensure that staff employed to arrange activities for residents are trained for that role. 3. 4. OP28 OP30 Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Broome End Care Centre DS0000017785.V318440.R01.S.doc Version 5.2 Page 29 - 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. 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