Inspection on 13/05/08 for Broome End Care Centre

This inspection was carried out on 13th May 2008.

CSCI found this care home to be providing an Adequate service.

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 14/05/07

Broome End Care Centre 01/11/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Broome End Care Centre Pines Hill Stansted Mountfitchet Essex CM24 8EX Lead Inspector Sharon Thomas Unannounced Inspection 13th May 2008 09:00 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.V364305.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.V364305.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 broomeend@schealthcare.co.uk Ashbourne Homes Ltd 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.V364305.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 14th May 2007 Date of last inspection Brief Description of the Service: Broome End is a three storey converted residence with a newer two storey extension, set in spacious grounds on the edge of the village of Stansted Mountfitchet. The home is registered to provide residential care for up to 37 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. The home has two passenger lifts to enable access to all floors. The gardens and grounds are at the rear of the home with ramps providing access. Ample off road car parking is provided to the front of the home for visitors, and bus services pass the building along the main road. Local shopping facilities are a short walk away. The weekly fees at the time of inspection in May 2008 ranged from £465.61 to £675.00. The fees did not cover hairdressing, private chiropody, toiletries or items from the tuck shop. Past inspection reports are available from the home, and from the CSCI internet website. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection commenced on the 13th May 2008 over a period of six hours. This report has been written using accumulated evidence gathered prior to and during the inspection. This included including documentary evidence was examined, such as menus, staff rotas, care plans and staff files. The manager completed an Annual Quality Assurance Assessment with information about the home. This document will be referred to as the AQAA throughout the report. All of the Key National Minimum Standards (NMS) for Older People, and the intended outcomes, were assessed in relation to this service during the inspection. Survey questionnaires were sent to the service to circulate to the people living there, relatives, healthcare professionals and staff to complete and return to the Commission. The responses received are included within the contents of this report. The visit included a tour of the premises, discussion with people living in the home, the deputy and acting managers, members of staff and one visiting relative. Observations of how members of staff interact and communicate with people living there have also been taken into account. The home is welcoming to visitors and staff, are friendly and courteous. People living in the home were very positive regarding the way that staff treat them, the food, and the comfortable and homely surroundings. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: This inspection visit has identified a number of regulatory shortfalls that must be addressed for the well-being and safety of people living in Broome End. These shortfalls were identified from viewing a random selection of records, from discussion, from completed surveys and from direct observation. The documentation used in the home to identify what people need and how staff are to give them the care they need does not always detail all of people’s care needs, how they are to be met and who by. Risk assessment documentation is not up to date or accurate. Medication administration records have gaps in recording, and so potentially placing people at risk. Activities need to be arranged by assessing people’s social needs and wishes. The home must re-implement the quality assurance so as to be able to measure how the service is meeting people’s needs. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 7 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.V364305.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6: Quality in this outcome area is adequate. People choosing to use the service are not always assured that their full range of needs will be assessed prior to moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager’s AQAA states “before any Service User is admitted to Broome End a Com 5 is obtained from social services if the service user is funded by Essex county council. A pre-admission assessment is completed; areas covered on pre admission includes personal care and physical well being, oral health, falls risk assessment, social interest, hobbies, continence, mobility, moving and handling, diet, dietary preferences, sight, hearing and communication, Family involvement. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 10 Although the home has not had many new admissions the pre-assessment records of three people were inspected. These records contained information from the placing authority and the home’s pre-admission assessment documentation was in place. We found that the document covered a range of individual needs but the document had not been fully completed by the management and did not contain detailed information. The acting manager acknowledged that some aspects of the pre-admission document had not been completed in full. This lack of information can result in the care plans not containing the full range of needs of the person and therefore staff cannot deliver the full range of care. Two people who live in the home said that they could remember that both they and their family members were involved in planning their care when they first lived in Broome End. Standard 6 is not applicable, as Broome End does not provide intermediate care. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 11 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, and 10: Quality in this outcome area is adequate. Overall people can be confident that their personal and healthcare needs will be met in Broome End and they may be confident that they will be treated with respect. However, people cannot be assured that their care plan documentation will identify all their care needs. Neither can they be assured that their risk assessment documentation and/or their medication administration records are robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of four people living in the home were inspected on this visit. Overall these care plans contained information relating to what people living in the home need. However some of this information was limited and did not always offer staff clear guidelines of how to deliver the care or how the person wanted their care to be given. The care plans did indicate that they are Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 12 reviewed on a regular basis, but one of the care plans did not contain up to date information on a person’s need that had changed. The care plans looked at did contain a copy of a risk assessment. But three of the four of these did not fully identify the risks and how staff are to manage these risks on a daily basis. One care plans stated that the person in question had some issues relating to weight loss, however there was not a risk assessment connected into this. Risk assessments are completed so that staff are aware of particular aspects of care that need to be addressed so as to reduce any further risks and keep people safe. Some staff spoken with on the day said that they do not always feel that they are providing care that completely matches the person involved. The emotional adjustment, loss of ability and cognitive impairment due to the onset of Dementia was not fully assessed or reflected within the care planning arrangements for another resident. Although the care plan was more detailed than others it did not instruct staff as to the care delivery, type and level of support required particularly with cognitive impairment related needs e.g. stimulation, communication, nutrition, memory loss and mobility. Recent entries in the daily reports stated ‘unsettled’ and ‘angry and kicking’, there were no risk assessments or risk management strategies within the care plan to support the individuals’ behavioural needs. Overall the care plans contained information relating to people’s healthcare needs but some of the entries were vague and follow up actions were not recorded leaving staff not knowing what had happened with a particular situation. Within the care plan documentation there is a place to record visits health care professionals. There had been some recent entries. The acting manager said that the home has a good working relationship with local health care professionals. The home operates a Monitored Dose System for administering prescribed medicines. A tour of the premises confirmed that medication is stored securely in a locked room. Medicines that are not dispensed into monitored dose or blister packs are kept in named plastic boxes. Opened medication is clearly marked with the date of opening. Medicines Administration Record (MAR) sheets were examined and were not completed accurately with at least five incidents where staff had not recorded whether the medication had been given or not. Controlled drugs are stored in a locked metal cupboard inside a locked cupboard in the locked room. The controlled drugs register was examined and all controlled drugs are signed for by the person giving the medication and witnessed by another member of staff; all entries examined were in order. Only senior staff administer medication following an assessment of competency by the manager. One member said they have not had an update of training Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 13 since their initial training approximately three years ago. However discussion with the acting manager confirmed that the service has identified all shortfalls in staff training and that medication training for staff was being provided on the day of the inspection. Two staff spoken with demonstrated an awareness of good practices around the storage and administration of medication. We observed medication being administered by a member of staff, who explained to the person what they were being given and encouraged them to take a drink with the medication. The acting manager and senior carer take responsibility for ordering and checking-in delivered medication and staff receive in-house training. At the time of the inspection no one living in the home was able to administer his or her own medication. Information within peoples’ surveys was mixed. For example, some thought there was ‘sufficient support from staff’, whilst others did not share this view. All felt that they receive good medical support and that staff listen to them. People spoken with were all positive about the care they receive and our observations confirm that people are happy, well looked after and were well dressed and groomed. Someone in the home who completed a survey some months before this inspection visit said, “I have lived here for more than a year now and am very well looked after and the staff are fantastic and caring”; another said they receive “Excellent care”. Another person said that the home helped them maintain their level of independence and would ask how they could help as apposed to making a decision for them. The manager’s AQAA states that “all Service Users have a detailed Care Plan that is evaluated as and when a need changes. All staff administering medication have received medication training, a Record of Competence assessment in place, Staff will have completed a course of safe handling of medication before the end of the year. Residents whom wish to self medicate are encouraged by assessment. Lockable storage provided, Self-medication assessment in place. Staff interaction shows respect, privacy and dignity to service users. Staff undertake Abuse POVA training and receive a copy of abuse and whistle blowing policy”. The information contained in the AQAA does not always accurately reflect the documentation and care practices actually carried out in the home. Comments received from visiting relatives and observations that we carried out during the inspection visit confirmed that people living at the home are treated with respect and their rights to privacy are maintained. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 14 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 and 15: Quality in this outcome area is good. Overall people living in Broome End have opportunities to maintain a lifestyle that meets their needs and wishes. This judgement has been made using available evidence including a visit tothis service. EVIDENCE: The sample of care plans we looked at showed us that there is limited information regarding peoples’ personal and social histories, personal choices, and daily social routines. Because of this, and the limits on discussion with those people with dementia, it is difficult to assess how well the daily routine caters for the individuals’ needs and choices. No real assessment of social need is evident in care plans although people’s participation in activities is recorded. Thus the social activity programme is not necessarily based upon peoples’ needs and choices. The sample of care plans examined showed that more work is required in order to demonstrate that peoples’ individual and social care needs are being met. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 15 Broome end offers people weekday activities including ball games, bingo, games afternoon, and some sessions in reminiscence and remembering and recall. The activity co-ordinator is very keen to provide a full programme of activity that will stimulate all of the people living in the home. She spoke of her plan to extend the type of activity that is provided in the home and that she is planning on buying some materials to prompt people’s memories and provide them with stimulation. One person spoken with said that “I don’t take part in the activities on offer but that is my decision and I could if I wanted” and another said, ”the staff try their best to keep us entertained, the birthdays are well celebrated”. A number of visitors were coming and going throughout the day. One person spoken with said they are happy now their relative has moved to Broome End. They have no complaints and say the care is good. Relative comments and staff spoken with indicated that the service encouraged relatives to maintain an active role in the peoples’ life following admission. Visitors spoken with on the day of the inspection said the home always provides a warm welcome, and they are able to visit family members or friends in private. Generally, residents were observed to be able to move around the home and involve themselves in activities and routines they felt happy doing. On the day of the inspection we saw people making some small choices including whether they wanted to stay in their room for lunch. People spoken with who are able to express their opinions are very positive about being able to choose the way they want things done. One person who chooses to spend most of their time in their room watching television is supported to do so, while others socialise in the lounge. People spoken with said that although generally they may choose not be involved in group type activities, they could if they wished to join in occasionally. People spoken with were positive about the food that they get in the home. The chef on duty had started work the day before the inspection visit. This person ids known to the CSCI and has the skills and knowledge around providing nutritional appetising meals. Food stores were examined and there was evidence of a variety of fresh quality food available. The dining room has an open plan layout, which ensures that meals are served up fresh and hot. We saw that mealtimes for people at Broome End are sociable occasions. Surveys received said there are “very good cooks with a choice of menu” and “The meals are varied and of a high standard”. Breakfast is served either in people’s bedrooms if they request it, or mostly as is the case, in the dining room. People are offered a choice of cereals or porridge, fruit juice, toast and marmalade and on Sundays they are offered Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 16 bacon and eggs in addition to the standard choice. The lunch on the day of inspection was appetising and people were offered a choice plus another alternative. This was confirmed in discussion with people who said they could have soup, omelettes, or salad if they did not want the main choice. Puddings included apricot crumble and custard, bread and butter pudding, fruit flan and cream, and jelly and ice cream. People spoken with said they had a good choice of puddings, and one person who enjoys them invited us to try some. In the afternoon a member of staff was observed to ask residents what they wanted for tea, from a choice of sandwiches or soup, eggs, cheese or beans on toast or anything that they requested. Some people require a soft diet for health reasons and these plus other specific needs are catered for. The manager’s AQAA states that: “activities calendar of events which include Outside entertainers every month, Religious service weekly, One to one activities for residents whom wish to remain in there rooms, Choice of Menus, quarterly relatives meetings. Protected Lunchtimes to ensure resident mealtime is not interrupted and thus ensuring residents are assisted at mealtimes if required”. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 17 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 and 18: Quality in this outcome area is good. People living in Broome End are kept safe by the home’s procedures around complaints and protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection we undertook a very in-depth look at how the service protects the people who live there. We found the following to be accurate. The home’s policy and procedure for Safeguarding Adults, as seen on previous inspections, is satisfactory, clear and precise and includes local procedures. Staff are made fully aware of safeguarding issues. The staff training files examined showed us that staff receive awareness training in safeguarding vulnerable adults and local procedures as part of their induction, and recent training records provided evidence that all staff have received safeguarding adults training. Staff records also showed us that staff were in receipt of a copy of the General Social Care Council (GSCC) Code of Practice and booklet two of the EVAPC guidance, for staff safeguarding adults. One area of concern was that upon discussion with the deputy manager she was not fully aware of the correct procedure to follow in the event of an allegation of abuse being made. Since late last year the home has come under close monitoring by Essex County Council and the service was required to refer all and any complaint to Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 18 ECC as a referral as a Safeguarding Adults issue. This resulted in the home making a large number of referrals to the local authority. Staff confirmed that they were not allowed to start work in the home until all of the correct checks were made and that had had training so they knew how to protect people in their care. They also confirmed that they knew how to use the home’s whistleblowing policy and would feel comfortable reporting any incident to the management. Relative’s surveys confirm that people are aware of how to make a complaint to and what response to expect. The manager’s AQAA states: “Copies of Complaint procedures is displayed in reception and service user guide. Staff receive yearly abuse training, all allegations of abuse is investigated using POVA guidelines, No staff employed without a POVA first check and CRB, If Staff employed with a POVA first check they will be supervised until CRB obtained. All residents and families are aware they can voice any concerns at any time through daily walk about from manager and relatives weekly surgery. We ensure that any problem is resolved immediately or investigated and responded to within our 28 days time scale. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 19 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 and 26: Quality in this outcome area is good. Overall people living in Broome End live in a clean warm and welcoming environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During a tour of the premises we saw that furnishings are domestic and comfortable and people living in Broome End benefit from the homely surroundings. All bedrooms located on the ground and first floor are single occupancy. They are individual and show ample evidence of personal possessions such as ornaments and photographs. Some rooms have ensuite toilet and wash hand basin while others have a wash hand basin. Discussion with people in their bedrooms showed that each room had an easy chair and it was noted that call bell cords were within easy reach of where the person was Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 20 sitting. Individuals confirmed that the response time to call bells “was not bad”. The acting manager was aware that some areas in the home needed redecoration and said that a programme has been developed and works were ongoing. The call bell system had a highly intrusive sound when call bells were used. This was identified in the previous inspection report. A range of communal areas are provided and include; a comfortable lounge area and a bright airy dining room. Communal areas have some signage to help people living at Broome End who have dementia, to negotiate their way around the home. Outdoor facilities include patio areas and a large garden that can be accessed safely from most parts of the building. A perimeter fence provides security and privacy. The gardens are well tended and provide people with a relaxing, quiet space to sit in. Laundry facilities are in place with systems in place to control the spread of infection. Washing machines used in the home includes sluicing facilities and a high temperature programme. Staff have been provided with training on how to reduce the risk of cross infection, how to clean properly, and what materials to use. Domestic staff do a very good job of keeping both the home and people’s equipment clean and hygienic. We saw staff wear personal protective clothing when carrying out ant personal or domestic care tasks. Staff said that they are provided with good training and support to ensure that the home is clean and that they themselves feel protected providing care in this manner. The manager’s AQAA states: “Service users personalised rooms. Decoration plan. Lounge space throughout the home that enables service users a choice of where and whom they sit with, Service users can meet with families/ Friends in private in their bedrooms or quite lounge. Enclosed Patio area for dementia care service users. Garden areas that are accessible to service users and wheelchair users. There is laundry facility that operates a clean/dirty system. We have a clinical waste contract and staff are trained in health and safety, which includes dealing with spillages, Protective clothing and Hand washing. Our washing machine meets the standard to ensure control of risk of infection. The people living in the home stated that they have a good domestic staff team. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 21 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 and 30: Quality in this outcome area is good. People living in Broome End benefit from a competent, well trained staff team who receive appropriate supervision. The recruitment procedure in the home provides the safeguards that ensure appropriate staff are employed This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was evidence on the day of inspection to indicate that the staffing levels were sufficient to meet the immediate presenting needs of the current number of residents. A clear staff rota was available for the presenting week. The acting manager confirmed that there is a minimum of six senior/care staff on duty between 8am – 8pm, seven days a week. There are three waking night staff on duty 7 days a week. The home employs a laundry person, a handyman, cooking staff and/or kitchen assistants are employed seven days a week. An activities coordinator is employed five days a week. Domestic staff are employed seven days a week. In addition, the rota recorded the hours worked by the acting manager and the deputy managers. Staff on duty during the day reflected the information on the rota. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 22 Records seen on the day confirm that the home meets the National Minimum Standard of having 50 with National Vocational Qualification (NVQ) at level 2 or above. The records indiocate that out of a total of thirteen care staff all but two have either completed or are in the process of doing NVQ at level 2 or above. The sample of personnel records examined contains evidence of NVQ awards. The staff training planner indicates that all staff have received training around the Protection of Vulnerable Adults. Staff training certificates are kept in personnel files. Records examined confirm that staff have received training in dementia, death, medication, pressure sore management and continence. The manager said that dementia training is ongoing. Staff spoken with were able to demonstrate a good knowledge of their responsibilities and ensuring they follow good practices. Observations on the day of the inspection also confirm that staff carry out their roles in a caring and professional manner. Overall people living in Broome End benefit from being cared for by a competent staff team. Staff spoken with had an acceptable understanding of peoples’ needs, but this is not supported by the home’s documentation system. For example, staff are aware that X could undertake some personal care tasks, but information on records concerning this matter regarding this was conflicting. Staff do not have sufficient written information about residents needs and therefore must be unable to provide a totally holistic approach to their care (see standard 7). Staff spoken with during the day were friendly, helpful and cooperative. All staff spoken with said they were happy to speak with the inspectors and indicated that they felt comfortable in doing so. Staff were observed to speak with people in a friendly manner and assistance given was supportive and caring. Staff recruitment files were sampled for four people. We found that the home has a thorough recruitment process and it does not employ people until all of the safety checks are carried out and they are satisfied with the results. The Annual Quality Assurance Assessment does not detail its recruitment procedures. The manager’s AQAA states: “Staffing Ratio is 1 to 5 at present. Staff rota is available detailing staff on duty role and hours worked. We have three waking night staff. All staff employed in caring role are above 18 years old. Staff left in charge of the home are age 21 and above.” Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 23 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 and 38: Quality in this outcome area is adequate. People can expect to live in a home where some management systems are improving and/or developing but at the same time they cannot be assured that all aspects of their day-to-day care are managed robustly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home resigned prior to this inspection visit. The CSCI was informed of this. The organisation has put an acting manager in place whilst the formal recruitment process takes place. The CSCI has been informed that a new manager has been appointed and will be in post by the end of May 2008. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 24 This, and previous inspections continue to highlight a wide range of areas that the manager needs to address in the home that will improve standards and affect outcomes positively for residents. These include care planning, social aspects of care, and essential elements of management such as quality monitoring and assurance. There were satisfactory systems in place to handle residents’ monies. Double signatures were used, receipts were available and balances checked were correct. The administrator said that systems were audited on a monthly basis. The home was not able to produce evidence that it has a quality assurance system in place. Supervision systems were in place and both group and individual supervisions were being carried out. The acting manager said that all staff would be receiving an annual appraisal. The home carries out weekly, monthly and annual safety audits of the building, the contents and equipment. The manager’s AQAA states: “registered Manager holds Registered Managers Award, 10years experience in elderly care. CRB being processed for registration of Home Manager. Yearly relatives and Service User Customer satisfaction surveys. 3 monthly Relatives meetings. 6 monthly service user meetings. Internal Auditing System in place monthly for medication, Home Audit. The information received does not reflect the current situation in the home and the organisation will have to ensure that the document is updated and reviewed to indicate where the service is at any given time. Broome End Care Centre DS0000017785.V364305.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Broome End Care Centre DS0000017785.V364305.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 OP3 Regulation 15(1)(2) Requirement All appropriate information must be gathered prior to people being admitted to the home, this information must then be used to generate the care plan. Care plans must contain detailed information that identifies all of the person’s needs, wishes, and interests. The information must be detailed enough for staff to provide appropriate care and support. Risk assessments must accurately reflect the risk to residents so that appropriate steps can be taken to reduce the risks identified. The activities programme must be expanded to reflect the assessed needs and wishes of the people living there. The home must record in full the social needs and wishes of individual. A quality assurance report must be sent to CSCI, which details the audits and surveys carried out and the improvements made DS0000017785.V364305.R01.S.doc Timescale for action 01/08/08 2. OP7 15(1)(2) 01/08/08 3. OP8 14(2) 01/08/08 4. OP12 16(2)(m) (n) 01/08/08 5. OP33 24 01/09/08 Broome End Care Centre Version 5.2 Page 27 to care and services as a result. The report must also address the health and safety and fire safety issues raised and include actions taken to improve the safety of the home for residents. 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 OP12 Good Practice Recommendations Records of daily activities should be of sufficient detail to ascertain the social stimuli and activities offered or taken part in by residents. Residents with dementia should have access to a safe and secure section of the grounds and access to the balcony should be restored. Pre-admission assessments should always be dated and signed. Care staff should be given additional guidance on how to complete dietary and fluid intake charts so that meaningful information is obtained, which can be used to improve healthcare for residents. The risk assessment forms should be reviewed to ensure that they are sufficiently flexible to accurately reflect risk and dependency of residents in the home. Resident’s preferences for food and drink should be documented so that care and catering staff are aware of their likes and dislikes. 2. OP19 3. 4. OP3 OP8 5. OP8 6. OP15 7. 8. OP21 OP37 An assisted shower should be installed in order to give residents a greater choice of bathing facilities. Records should be maintained in accordance with the Data DS0000017785.V364305.R01.S.doc Version 5.2 Page 28 Broome End Care Centre Protection Act 1998 in order for the confidentiality of residents’ personal information to be maintained. Broome End Care Centre DS0000017785.V364305.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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