Inspection on 14/05/07 for Broome End Care Centre

This inspection was carried out on 14th May 2007.

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

The inspector 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Broome End Care Centre Pines Hill Stansted Mountfitchet Essex CM24 8EX Lead Inspector Unannounced Inspection 14th – 29th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Broome End Care Centre DS0000017785.V339072.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.V339072.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 a subsidiary of Southern Cross Healthcare 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.V339072.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 27th March 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 2007 ranged from £437 to £664. 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.V339072.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out over two days on 14th and 15th May 2007. Throughout the report the term resident is used to describe people living at Broome End Care Centre. The inspection included discussions with 10 residents, although advanced dementia made communication difficult with a few of them. 1 relative was spoken with during the inspection and 3 were telephoned following the inspection. 8 staff including the acting manager were spoken with during the inspection. Feedback following the inspection was given to both the acting manager and the operations manager. Additional information was requested at inspection and was received on 29th May 2007. This concluded the inspection process. The last key inspection was carried out on 1st November 2006. Since that date two additional unannounced visits were carried out by CSCI on 12th January 2007 and 27th March 2007, due to concerns about the management at Broome End Care Centre and in order to follow up on outstanding requirements from previous inspections. An unannounced CSCI pharmacy inspection was also carried out on 19th April 2007 following concerns about the management of medicines. Essex County Council (ECC) had also carried out a number of additional inspections following a high volume of protection of vulnerable adult (POVA) referrals. A number of meetings had been held with CSCI, ECC and Southern Cross Healthcare during which it was agreed that standards at the home needed to be improved. A new acting manager was appointed in February 2007. Considerable additional managerial input was also being provided to support the new acting manager. What the service does well: What has improved since the last inspection? The management of the home had improved. One relative considered that there had been “great improvements recently” in the home and said “the manager’s door is always open”. There had been considerable improvement in staff training, supervision and on assessments of staff competence. There had been particular emphasis on improving the standard of moving and handling and ensuring that the staff had the appropriate equipment. A resident said Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 6 “The food has much improved in the last month and presentation has also improved”. The area of subsidence in the garden had been addressed and returfed. The new acting manager was encouraging an open and positive culture in the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Broome End Care Centre DS0000017785.V339072.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.V339072.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): Standard 3 (standard 6 not applicable) Quality in this outcome area is adequate. An assessment is carried out to ensure that the home can meet prospective residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A pre-admission assessment was carried out for potential residents to ensure that their needs could be met. Only one pre-admission assessment was seen, as there had been no recent admissions. The assessment contained an adequate range of information but was not signed or dated. Information was also obtained from the social services assessment where appropriate. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 Quality in this outcome area is adequate. Residents and relatives are satisfied with standards of care. Care records do not fully reflect residents’ needs and wishes. Medicines management needs to be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives spoken with were generally very satisfied with the standard of care at the home and said that standards had recently improved. Staff were observed to be very caring and to treat residents in a respectful manner. The home had a range of care plans and risk assessments for each resident that had been regularly reviewed. However, they were not resident centred and there was very little evidence that residents or their representatives had been involved in their development or evaluation of their care and care needs. Some of the risk assessments seen did not accurately reflect the risk or the dependency of residents as identified during discussion with residents and staff Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 10 (this was in part a problem with the forms themselves). One resident had lost 20kg in weight over a period of seven months but this was not identified on either the risk assessment or the care plan. Another resident was registered blind according to the assessment but staff spoken with were not aware of this, and it was not reflected in the risk assessments or care plans. Dietary and fluid intake charts were being used for a few residents but generally needed to be more detailed to provide an accurate assessment of nutritional intake. In some instances staff needed to provide more evidence that they were monitoring residents’ psychological health and wellbeing. Some of the moving and handling assessments and care plans were detailed and of a very good standard. Two new hoists and a number of different sized slings had recently been purchased. Staff at the home reported that they had very variable support from their local GPs and community nurses. Issues identified were being taken up with the local GP practice and the Primary Care Trust. The acting manager was aware that residents had not had recent medication reviews and was taking steps to address this. Medicines management still needed to be improved. All staff who administered medication had received training and an assessment of competence. A discussion was held about the need for the staff who received and logged the monthly supply of medicines to have additional training as these records needed to be improved. It was noted that four residents did not receive their prescribed medication for a number of days. Although staff were in part responsible for these delays, there were also considerable problems with the method one GP used to prescribe and issues with the dispensing pharmacy. There was evidence that on at least one medicine round staff had not administered medication from the residents’ own supply as some residents had less and some residents more medicines than they should have had of two medicines (a laxative and a calcium supplement). In some instances staff were not giving medicines (painkillers and laxatives) regularly as prescribed and they were advised to ask the GP to change the prescription to “as required” where appropriate. Staff also needed more guidance on the medication administration records on how to give some “as required” medicines. Staff were reminded that prescription only topical creams in residents’ rooms needed to be kept in a locked drawer. A number of medicines had a prescription label on the outside carton but not the inner container. As some residents were on the same medication there was an increased risk of cross infection if the medicines became separated from their cartons. Some medicines with a limited shelf life on opening had not been dated on first use. The temperature of the cupboard where some of the medicines were stored was being monitored and was frequently above 25c, which is the safe upper Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 11 limit for the majority of medicines. The temperature of the area where the medicine trolleys were being stored was not being monitored. The acting manager said that a new storage area for all the medicines was due to be created in the near future. The procedure for taking verbal orders for changes in medicines had been improved. Staff confirmed that they did not take verbal orders for any newly prescribed medication. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 Quality in this outcome area is adequate. Activities and stimulation in the home, particularly for people with dementia, needs to be developed. The standard of food is improving but residents’ specific nutritional needs are not always met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities had been identified, in a recent relatives survey, as an area that needed to be improved. The acting manager said that the provision of activities was due to be discussed at the next residents’ and relatives’ meetings. A part-time activities co-ordinator was appointed for 20 hours each week in December 2006. She was still in the process of receiving induction but had received limited training in the range of activities for older people and people with dementia. A discussion was held about the possibility of her undertaking a National Vocational Qualification (NVQ) in activities. Residents spoken with said that they enjoyed the activities every week and the occasional entertainments, but said that there had not been any recent trips out of the home. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 13 One resident who preferred to spend more time in their room said “I don’t get the chance to chat to anyone. There’s no regular visits in people’s rooms”. There were very few care plans that related to social activities, to stimulation and to residents’ interests, and the records of activities needed to provide more detail. The activity co-ordinator described how a resident with dementia, whose relatives could not visit, had been assisted to buy a mobile phone and supported to make phone calls. This is to be commended. However, a discussion was held about the need to ensure that residents at all stages of dementia had access to an equal range of activities as other residents in the home. There was evidence that a few of the care staff were providing or assisting with some activities and stimulation, but this was an area that needed to be developed further. The number of activity co-ordinator hours will need to be kept under review as occupancy in the home rises. The home had links with the local community. There was a nondenominational service each week in the home and fortnightly communion. One resident had regular individual communion in the home. There were also occasional entertainments including dancing and singing, which residents said they very much enjoyed. The manager had set up a weekly relatives’ surgery on a weekday evening. Relatives said that they were made to feel very welcome when they visited. Staff were able to give positive examples of how they gave residents’ choices and encouraged them to maintain independence Menus and food was identified, in a recent survey, as an area that could be improved. The acting manager said that menus and food were to be discussed at the next residents’ and relatives’ meetings. A comments folder had also been set up with the chef in order to record residents’ feedback. There was limited recording of residents’ preferences for different food and drinks, but staff confirmed that residents were given choices at all mealtimes and offered alternatives if they did not like what was on the menu. Residents were generally happy with the food and one commented that the food and presentation had improved in the past month. There was not always evidence that appropriate steps were being taken to address residents’ specific nutritional needs, for example weight loss (see standard 8). Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18 Quality in this outcome area is good. An open and positive culture towards concerns and complaints is being encouraged. There are good systems in place to prevent abuse and monitor standards of care practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure, which was on display in the entrance hall. The acting manager was publicising the complaints procedure. She was also encouraging residents and relatives to take up any issues of concern with her, if they were not sorted out to their satisfaction when initially raised. Residents and relatives were aware of how to raise concerns. The acting manager said that all staff had received POVA training. All staff had received a copy of the Essex adult protection guidelines and the whistle blowing policy. Staff spoken with had a good understanding of the different types of abuse that could occur and the action to take if abuse was suspected or poor practice observed. There had been concerns about the number of protection of vulnerable adult referrals from the home. At the inspection there was evidence of improved monitoring of standards of care, increased training and supervision of staff and action taken to reduce accidents and falls. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21, 24, 26 Quality in this outcome area is adequate. There are plans to carry out redecoration and change the call bell system. Residents with dementia do not have access to a safe area of the garden. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager was aware that some areas in the home needed redecoration and said that a programme would be developed in the near future. The call bell system had a highly intrusive sound when call bells were used. The acting manager said that there was a proposal to change the system and incorporate a personal pendant for residents and pressure mats (see standard 38). The part of the garden with subsidence had been investigated and the area filled in and re-turfed. The home had extensive grounds and residents said that Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 16 they very much enjoyed watching the wildlife in the garden. Residents in one of the lounges said that some overgrown shrubs obscured their view of the garden. The acting manager was informed and the shrubs were cut back within 24 hours. The acting manager said that there were plans to create a sensory garden with new garden furniture for residents. Residents with dementia on the second floor of the newer wing had no access to a safe part of the garden. Access to the balcony area on the second floor had been restricted due to the potential hazard of the step. The plants in pots on the balcony needed attention to improve the view for residents on this floor. The drive to the home was full of potholes. The operations manager said that the drive was not part of Southern Cross property but that they would investigate whether the company could improve the surface. The home had one assisted bath (Parker bath) out of action at the time of inspection and was awaiting parts from abroad. There was one other Parker bath, which could be used for highly dependent residents. Staff said that the assisted bath for semi-dependent residents was not popular and was not used. There was also a bath for residents who were more independent but this was also not used. A discussion was held about the benefit of installing an assisted shower in order to provide residents with a greater choice of bathing facilities. The locks on doors that were seen were not of the kind that could be easily used by residents and could open easily with a handle on the inside. The home was clean and there were no unpleasant odours on the day of the inspections. Residents were happy with the laundry service. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 Quality in this outcome area is adequate. The majority of residents are generally satisfied with staffing levels. Recruitment procedures are generally sound. Training is being given a high priority. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels for care staff at the time of inspection were 6 staff from 08:00-14:00, 5 staff from 14:00-20:00 and 3 staff from 20:00-08:00. The acting manager said that they had kept to the agreed levels even though they had a number of empty beds and only had residents on four floors. However, due to layout of the home and the dependency of residents at the time of inspection these levels would need to be reviewed as numbers of residents in the home increased. The acting manager was supernumerary. The deputy manager was usually supernumerary for one day each week, but at the time of inspection was fully supernumerary unless cover was required at short notice. The home had appropriate administrative, catering and domestic support. The home had been without a maintenance person for a period of time prior to the inspection and some additional support had been provided from other homes in the company. One resident said “The staff are very good but there are too many agency staff”. Residents commented that there had “been a lot of changes of carers”. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 18 The majority of residents spoken with considered that they usually did not have to wait too long for staff to respond to call bells. Although a relative said that one of the residents, who had more complex needs, did consider that they frequently had long waits for assistance to go to the toilet. This resident was particularly concerned about asking for assistance at night. The sample of staff records seen demonstrated that criminal records bureau (CRB) and protection of vulnerable adult (POVA) list checks had been carried out and the required information was obtained prior to staff taking up employment. However, the original CRB disclosure forms were not available, and the company was not able to give assurances that a representative from the Commission had inspected them at the central location where they were being held. There were interview questions and records of answers, which was good employment practice. There had been a considerable emphasis on staff training in the period prior to the inspection. 3 staff had started their NVQ level 3, 5 staff had started NVQ level 2 and 5 more were due to start level 2 shortly after the inspection. All staff who had been appointed in the past six months were undertaking an induction based on the Skills for Care common induction standards. A discussion was held with the acting manager about ensuring that the induction included the knowledge sets for dementia and that all staff received dementia care training. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 19 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): Standards 31, 33, 35, 37, 38 Quality in this outcome area is adequate. Standards in the home are improving. Steps are being taken to reduce accidents and falls. Staff are receiving regular supervision and training. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The acting manager had completed the registered manager award and had management experience prior to taking up the post at Broome End. She demonstrated a commitment to improving standards of care and services in the home, and had an open style of management. The home had systems in place to monitor quality of services and care in the home. Considerable resources had recently been put into the home to improve Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 20 standards. A number of audits and surveys had been carried out including a relatives survey in April 2007. An overall quality assurance report had not been forwarded to CSCI and this was requested at the time of inspection. 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. 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. Staff were using a “doctors’ book” to record residents’ medical problems and concerns to discuss with the visiting GP. The GP was also using the book to record changes in treatment. Staff were advised that this did not comply with the Data Protection Act 1998 and that any list of information to discuss with the GP must be destroyed once details of residents’ treatment and care had been transferred to their individual folders. The home had carried out an analysis of accidents and falls in the home in the past four months and was taking steps to reduce them. The actions being taken included updating moving and handling assessments, the purchase of additional moving and handling equipment and assessment of staff competence in moving and handling. Staff were also mapping and reporting any bruising or injury regardless of whether they had observed the accident. Training in falls prevention was also being arranged. The company was also investigating the possibility of purchasing pressure mats to alert staff if residents (who were unsteady on their feet) got out of bed. If purchased the mats would only be used with agreement from residents and their representatives and following an individual risk assessment. The accident analysis demonstrated that reported accidents and falls in March and April 2007 had halved from those reported in January and February 2007. The company carried out a health and safety audit of the home and grounds on 24th April 2007. The home did not comply with all the standards audited, but this was in part due to the fact that they had been without full maintenance support for some time. A new maintenance person was due to be appointed in the near future. There was evidence of systems in place for service and maintenance of equipment. A number of fire doors were wedged open, as residents did not want their doors shut. Fire drills had not been carried out since the beginning of the year. The fire service had carried out an inspection in April 2007 but the home had not received the report at the time of inspection. Training in safe working practices had been given a high priority prior to the inspection. The home had an analysis of staff training needs and was taking steps to address them. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 22 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. The following requirements were discussed with the acting manager at the time of inspection. No. 1. Standard OP7 OP12 Regulation 15(1)(2) Requirement Care plans must be drawn up in consultation with residents, and their relatives where appropriate, so that their needs, interests and wishes can be reflected in the plans and staff can provide appropriate care and support. Risk assessments must accurately assess the risk to residents so that appropriate steps can be taken to reduce the risks identified, this particularly refers to addressing nutritional risk. The issues surrounding the prescribing and supply of medicines must be resolved so that residents receive their medicines as prescribed. Staff receiving the monthly supply of medicines must record this in such a way as to leave a clear audit trail for all medicines and so that checks can be made DS0000017785.V339072.R01.S.doc Timescale for action 01/08/07 2. OP8 OP15 14(2) 01/08/07 3. OP9 13(2) 01/08/07 Broome End Care Centre Version 5.2 Page 23 on whether residents have received their medicines correctly. 4. OP12 16(2)(m) (n) The activities programme must be expanded so that residents with dementia have access to an equal range of social activities and stimulation as other residents in the home. All staff must have training that emphasizes the importance of social stimulation and activities and their contribution to improving the quality of life for residents in the home. 01/08/07 5. OP12 18(1) 01/12/07 6. OP24 12(4)(a) The locks on residents’ rooms 01/09/07 must be assessed to ensure that they are suited to their capabilities, can be easily opened from the inside and are accessible to staff in emergencies, in order to protect residents’ privacy and independence in a communal setting. The staffing levels must be kept under review to ensure that there are sufficient staff to meet the needs of more dependent residents’ at night. Systems must be put in place for the original Criminal Records Bureau disclosure forms to be inspected by the Commission, so that evidence is provided of recruitment practices that protect residents. All staff must receive dementia care training in order to ensure that they can provide appropriate care and services to residents with dementia. DS0000017785.V339072.R01.S.doc 7. OP27 18(1)(a) 01/08/07 8. OP29 18(1) 01/09/07 9. OP30 18(1)(a) 01/12/07 Broome End Care Centre Version 5.2 Page 24 10. OP33 OP38 24 A quality assurance report must be sent to CSCI, which details the audits and surveys carried out and the improvements made 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. 01/09/07 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 OP3 OP8 Good Practice Recommendations 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. Records of daily activities should be of sufficient detail to ascertain the social stimuli and activities offered or taken part in by residents. Residents preferences for food and drink should be documented so that care and catering staff are aware of their likes and dislikes. Residents with dementia should have access to a safe and secure section of the grounds and access to the balcony should be restored. 3. OP8 4. OP12 5. OP15 6. OP19 Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 25 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 Protection Act 1998 in order for the confidentiality of residents’ personal information to be maintained. Broome End Care Centre DS0000017785.V339072.R01.S.doc Version 5.2 Page 26 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. 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