Inspection on 11/05/05 for Broome End Care Centre

This inspection was carried out on 11th May 2005.

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 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 01/11/06

Broome End Care Centre 28/11/05

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 Sharon Thomas Unannounced 11th May 2005 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 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 I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 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 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 01279 814598 Ashbourne Homes Ltd Donna Masson Care Home 37 Category(ies) of Old age, not falling within any other category 37 registration, with number Dementia - over 65 years of age (DE(E)) 1 of places Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 37 persons) 2. One person, over the age of 65 years, who requires care by reason of dementia, whose name was made known to the National Care Standards Commission in December 2003 3. The total number of service users accommodated in the home must not exceed 37 persons Date of last inspection 26/01/05 Brief Description of the Service: Broome End is a large detached house located in Stanstead Mountfitchet. The home is registered to provide residential care to 37 older people (over the age of 65), with varying degrees of dependency. Residents live in 29 single rooms and 4 double rooms. The home has several lounges and a dining room and provides access, through ramps, to the garden and patio areas. The upper floor is accessed via a passenger shaft lift. The home provides personal care to residents, and is fully equipped to provide a safe environment to those with restricted mobility. The homes bathrooms and toilets are equipped to enable residents to maintain their independence. Broome End has a well-trained staff group, who have a sound knowledge of the service users and their needs. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 11th May 2005, and took 6.5 hours. Fifteen of the thirty-eight National Minimum Standards were inspected: thirteen were met, and two were nearly met. This inspection was carried out in response to a complaint that the CSCI received regarding a resident found outside the home. This issue was investigated and the inspector was satisfied that the manager and staff have taken the appropriate action to remedy the situation. For the purpose of this report the individuals living in the home spoken with on the day stated that they would prefer to be called residents. The inspection process included: discussions with the manager, care manager, three members of staff, the cook, and eight residents. The tour of the premises included observation of seven bedrooms, all of the bathrooms and toilets, all of the communal areas, the kitchen and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home was warm clean and tidy. The residents spoke highly of the care that they receive in Broome End and spoke highly of the efforts of the staff. What the service does well: The home provides a warm and homely atmosphere for residents. The home has created a family atmosphere despite its size. The information held in the home about individual residents (care plans) clearly detail a full range of social, emotional, and physical needs. Comprehensive detail of the care needed to meet these needs was evident. The menu in the home provides a well-balanced and varied diet for residents. The kitchen was well stocked, clean and well maintained. Broome End has a good caring staff team, and has a low staff turnover, staff that have left have done so for genuine reasons, such as retirement. The staff group in Broome End are enthusiastic, well trained and skilled. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 6 All of the residents spoken with on the day stated that the manager and staff were ‘kind and caring’ and the home was ‘very nice’. Residents reported that relatives and visitors are welcomed into the home at all times. Some of the activities provided in the home are specifically designed to provide stimulation for residents with dementia including chair games to promote physical exercise and interaction with the other residents and staff. The staff were observed to chat continually with the residents and involve them as they went about their work through out the day. The home has close links with the health care team in the area, and works with both professionals and residents to promote and maintain the residents health. The home promotes the rights of the residents and staff provide care that ensures privacy and dignity. The residents interacted comfortably with the staff. What has improved since the last inspection? What they could do better: Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 7 The records for the disposal of medication need to be accurately maintained. Provide an environment to ensure that the safety and welfare of the residents is maintained, and must ensure that the external structure is safe for residents. Sufficient numbers of staff are on duty at all times. Every effort must be made to cover staff sickness and absence. 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. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 9 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 standard(s) 4. The home is able to meet the various needs of the residents living there. The service is able to meet the assessed needs including specialist/changing needs of the current residents living at Broome End. EVIDENCE: There was evidence that a good level of staff training was being provided in Broome End. The staff spoken with demonstrated a good understanding of the individual and collective needs of the residents. These needs were reflected in full detail in the care plans and relevant assessments. Positive care practices were observed on the day. All residents spoken to were very positive about the care provided at Broome End, and felt confident that the staff had the skills to deliver the support and care that they required. One resident commented that they felt that the staff “were good at their job, and understood me”. Broome End does not provide intermediate care service. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 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 standard(s) 7, 9, & 10. Care plans were detailed and comprehensive. The administration of medication is safe, and reflects the homes policies and procedures. The home provided a service that treated the residents with respect, staff engaged positively with residents and demonstrated a good understanding of their needs. EVIDENCE: Three care files were examined. All contained detailed information regarding the resident’s need, the action to address this need, and the long-term outcome of the care given. The care plans covered all aspects of a resident’s physical, mental and social needs, and were reviewed on a monthly basis. There were detailed risk and manual handling assessments. There was evidence that residents signed care plans and were involved in the planning process. Residents spoken with confirmed that the staff in the home provided them with a good level of support and assistance. They commented that the staff knew “the little things about me” and that staff “do a very good job to look after all of us”. Staff were observed treating residents with care and Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 11 sensitivity, one resident who became distressed received calming re-assurance from staff, and this action was reflected in the resident’s care plan. Four residents in the home are able to self medicate and their care plans contained a risk assessment. The home had a clear and comprehensive medication policy and procedure. The medication administration records of all medication used in the home were accurate and up to date, as were the records of receipt. The records of disposal were not accurate. The staff spoken with confirmed that they had received appropriate training and support, and were confident that they ensured the safety of the residents when giving medication. During the inspection the staff were observed giving a friendly and respectful service to residents. The staff spoken with confirmed the importance of privacy and dignity and discussed how they maintained these issues in their daily care practices. Residents spoken to reported that staff were “patient and kind,” they assisted residents to preserve their dignity and assisted them with their personal care needs in a professional manner. One resident confirmed that they had made a choice regarding who they wanted to assist them with their personal care needs and that this choice had been supported by the staff. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 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 standard(s) 12 & 15. The home provides an environment that meets the social and recreational preferences of the residents. There is a full range of activities to meet residents’ varying needs. The home provides the residents with a varied, nutritional and wholesome diet that addresses specific individual’s need. Mealtimes are a social occasion and set in comfortable surroundings. EVIDENCE: Broome End has a dedicated activity co-ordinator who works 20 hours a week. The activity programme offered a variety of social activity that was appropriate to the needs of the residents. The care plans sampled detailed the social and recreation needs of the residents. The residents were observed spending time in various parts of the home, communal areas and in their bedrooms. The residents spoken with confirmed that the home provided a variety of activities in line with their preferences. Two residents reported that although they did not participate in the activities that were provided, the staff always “invited me to join in”. The menus examined reflected that the home provided residents with a variety of well- balanced, nutritional meals. The kitchen was clean and well organised, and the food stocks were high and of good quality. Meals are freshly prepared Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 13 and cooked by the chef who has a great deal of experience. The chef was knowledgable and skilled and has undertaken over and above the required training for her role. The meal presented on the day was appealing and the residents stated that the quality of food in the home was “excellent”. Residents confirmed that the meals provided in the home were “always tasty” and “well prepared” and “the cook was very capable”. Fresh fruit and snacks were available throughout the day, and residents confirmed that they could have a drink or snack at any time. When required, meals are liquidised and special dietary needs are catered for. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 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 standard(s) 16. The home has an effective system in place to enable residents, relatives and others to make complaints. EVIDENCE: Broome End has amended the complaint procedure, and this was found to be clear and concise. The document directed the individual how and to whom, to make a complaint. It contained timescales for action, and the details of the CSCI. It was written in plain language and was user friendly. All of the residents spoken with confirmed that they were aware of the Complaint procedure, and they were able to confirm that they knew who to complain to. The residents reported that they had no cause to complain. They commented that they felt confident that their concerns would be dealt with immediately. The complaint log was examined and was accurate and well maintained. The staff spoken with confirmed that they were aware of the importance of enabling residents to make complaints. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 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 standard(s) 19, 25 & 26. Overall the home provided residents with a safe, well decorated, and well furnished place to live. The home was clean, warm and had high standards of hygiene. EVIDENCE: Broome End is a large property that has been adapted to meet the needs of the residents. The home has a ‘fit out and decorating plan’ for the year. This provided evidence of the planned redecoration of communal areas and resident bedrooms. On inspection of the grounds the inspector noted that two wooden pillars supporting a resident patio area had rotted and were in need of immediate repair to ensure the safety of the residents. The remainder of the grounds were well maintained and safe. The Fire Officer and Environmental Health reports were examined and no concerns were recorded. On touring the home all areas were found to be clean, tidy and free from odour. The furnishings and decoration were of a high standard and gave the home a warm and welcoming feeling. The temperatures of the hot water from the taps in the bathrooms were recorded and were found to be at appropriate Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 16 levels. The home’s communal and private areas are naturally ventilated. All bedrooms are centrally heated and radiators are guarded to ensure the safety of residents. The lighting in the home is domestic in nature, and emergency lighting is provided throughout the home. The residents spoken with reported that the “home was always clean and tidy” and that “the staff are really good at keeping my room clean”. The home’s laundry facilities are located away from communal areas and individual bedrooms reducing the risk of cross infection. The equipment in the laundry is suitable for the needs of the residents. The home has two sluices in operation and these were clean and well-maintained. Residents confirmed that their clothes were returned from the laundry “smelling nice and well ironed”. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 30. The home provided appropriate training to give staff the skills necessary to do their job. Staffing levels (number and competence) met the needs of current residents. There is a stable and loyal staff team, which ensure consisitency in the delivery of care. EVIDENCE: The staff rota examined reflected that the home was providing the agreed levels of staff. However on the morning of the inspection the home had one member of staff absent, the manager had attempted to fill this absence but was unsuccessful. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. Records confirmed that 1 member of staff in the home had achieved the NVQ Level 2 qualification, while 10 members of staff were undertaking this award. The home provided the staff with a full and comprehensive programme of training. The programme included: First Aid, Fire Safety, Moving & Handling, Food Hygiene, infection Control, Medication, Continence, Pressure care prevention, and Falls Prevention The staff spoken with reported that the training provided was relevant to their roles in the home and helped them to do their job better. Two members of staff reported that Dementia training would be beneficial to both the staff group and the residents. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38. The home has a secure system to safeguard the residents’ financial interests. There were comprehensive health and safety systems in operation to ensure the ongoing welfare of both residents and staff. EVIDENCE: Four resident personal allowance records were sampled. All four sets of records were accurate and well maintained. The money held in the home for residents is held in a safe in a locked room. The home does not act as appointee for any resident living there. The residents’ families are responsible for the financial matters of individual residents. The home provided staff with appropriate Health and Safety training. Risk assessments of the premises were undertaken and regular Health and Safety checks of facilities and equipment were also undertaken. The manager was aware of relevant Health and Safety legislation and was committed to the welfare of both the residents and staff group. Hot water, fire alarm and Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 19 equipment checks were accurate and up to date. The staff spoken with were committed to the safety of the residents and were able to discuss the potential hazards in the home. The staff stated that they would report any safety hazard to the manager who would take the appropriate action. The staff also confirmed that they would use the resident risk assessment to ensure the safety of the residents. Staff were aware of Health and Safety issues around the home and wore personal protection clothing when needed. Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 3 3 STAFFING Standard No Score 27 2 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x 3 x x 3 Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 14 (1) Schedule 1 Requirement The registered person must ensure that the Service User Guide contains all of the information under the Care Home Regulations 2001. The Service User Guide must be a separate document and detail all of the requirements of the National Minimum Standard.This is a repeat requirement as this was not inspected on 11.05.05. The registered person must ensure that staff are not employed until the manager receives all of the information required under this regulation.This is a repeat requirement as this was not inspected on the 11.05.05 The registered person must ensure that the external wooden pillars are repaired or replaced to ensure the ongoing safety of the residents. The manager should considered securing this area until the above action is carried out. The registered person must ensure that suitable and sufficient numbers of staff are on duty at all times. Timescale for action 31.07.05 2. OP29 7, 9, 19 Schedule 2 31.07.05 3. OP19 23 (1) (a) 31.07.05 4. OP27 18 (1) (a) 11.05.05 Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 22 5. OP33 24 (1) (a) The registered must ensure that the home’s Quality Assurance system is implemented and the published results are sent to the CSCI. This is a repeat requirement as this was not inspected on 11.05.05. 31.07.05 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. Refer to Standard Good Practice Recommendations Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Fairfax House Causton Road Colchester CO1 1RJ 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 Broome End Care Centre I56-I05 s17785 Broome End v227048 110505 stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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