Inspection on 28/11/05 for Broome End Care Centre

This inspection was carried out on 28th November 2005.

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

The inspector 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 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 Sharon Thomas Unannounced Inspection 28th November 2005 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.V272570.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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 Donna Masson Care Home 37 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (37) of places Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 37 persons) 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 The total number of service users accommodated in the home must not exceed 37 persons 10th June 2005 3. Date of last inspection 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. Broome End 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 DS0000017785.V272570.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 28th November 2005, and took 4.5 hours to complete. Nine of the thirty-eight National Minimum Standards were inspected: five were met, and four were nearly met. 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 two residents. The tour of the premises included observation of eight bedrooms, all of the bathrooms and toilets, all of the communal areas, the kitchen and the laundry. There was an opportunity to spend a 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 to make them feel at home. What the service does well: The residents living in Broome End benefited from an established and knowledgeable staff group who gave sensitive and professional care. The staff have an in-depth knowledge regarding the needs of the individual residents in their care. The routines in the home are as flexible as possible and are changed to the meet the varying needs of the residents. Relatives and visitors are welcomed into the home and residents felt that the home done everything possible to make sure that their relationships were maintained. The environment in the home was considered safe and well maintained. The home had a warm and homely feeling. The residents spoken with on the day reported that they felt “warm and comfortable” and “at home”. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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’. The home provides a warm and homely atmosphere for residents. The home has created a family type atmosphere despite its size. What has improved since the last inspection? What they could do better: The home did not gather sufficient information prior to the admission of residents in the form of an up to date, relevant social services assessment. The completed pre-admission assessments seen on the day did not contain enough detail to generate the resident’s care plan. Overall the lack of information may result in the inappropriate admission of an individual and may place that person at risk. The information held on files about residents needs to be improved to ensure that the care being given by staff is safe and appropriate. The information should identify all aspects of the care needed by individuals and to give clear guidance to staff to enable them to deliver the care required by the resident. The care plans did not provide sufficient information about the healthcare needs of the individual residents. Broome End did not provide residents with a full range of suitable social activity. The home did not have a robust recruitment procedure. Staff personnel files did not contain all of the information required to ensure that appropriate staff are employed. The lack of appropriate checks has the potential of placing residents at risk. The home did not provide residents and relatives with information regarding the advocacy service available to them. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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.V272570.R01.S.doc Version 5.0 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 the following standard(s): 3 The home did not receive all of the appropriate information required prior to the admission of a resident. The lack of information may result in the inappropriate admission of a resident and place that person at risk. EVIDENCE: One of the three care plans sampled was that of the newest admission into the home. It did not contain a social services assessment. This situation is cause for concern and was discussed with the manager on the day. It was agreed that prior to any future social services admissions the manager must ensure that the home is in receipt of a social services assessment that is up to date and relevant to residential care. The pre-admission assessment used by the home for the care plan of the newest resident (as above) was not detailed and did not contain sufficient information to ensure a safe admission. There was no evidence that the resident and their family were involved in the care planning process. Two of the three care plans sampled did not contain sufficient information some ten weeks after admission. An immediate requirement notice was left at the home to ensure action was taken to ensure the safety of the residents. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 10 Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 8. Care plans examined indicated that the home’s care planning systems are insufficient. The residents care needs were not fully identified, planned for, or monitored in an appropriate manner. The shortfalls identified have the potential of placing resident at risk. There are systems in place to ensure that residents’ health care needs are met, however, the home is not meeting all of individual residents identified needs. EVIDENCE: Three care files were examined on the day of the inspection. None of the three contained sufficient information regarding the resident’s need, the action to address this need, and the long-term outcome of the care given. The care plans did not cover all aspects of a resident’s physical, mental and social needs, and were not reviewed on a monthly basis. Risk assessments and manual handling assessments were not completed with enough detail to enable staff to deliver care that is safe and appropriate. The concerns regarding the lack of information contained in care plans was discussed with the manager and it was agreed that urgent action to address this situation would to be taken by the manager and staff. There was no evidence that residents signed Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 12 care plans or were involved in the planning process. However, residents spoken with confirmed that the staff in the home provided them with a good level of support and assistance. The care files examined did not contain a sufficient range of additional assessments based on the healthcare needs of the residents. These included continence, nutrition, mobility and moving and handling, and pressure areas, as well as risk assessments relevant to individual need; many of these assessments were not completed. Personal care tasks were not recorded, although it was clear that the staff promoted independence in personal care where possible. The assessments have not been regularly reviewed or updated to include a change in need. From discussion with the staff it was clear that they had an awareness of the action required to meet these needs, but the recording in care plans was not sufficient to guarantee the safe delivery of care. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14. Broome End is not fully meeting the social and recreational preferences of the residents with regard to activities provided in the home. The home provides the residents with flexibility and choice with regard to their daily lives. The home encourages contact with families, friends and the local community. EVIDENCE: Broome End has a dedicated part time activity co-ordinator. There was an activity programme on display, however this did not offer a formal variety of social activity that was appropriate to the needs of the residents. The activity programme was repetitive and offered little stimulation to the residents: sweet trolley as one of the activities. The care plans sampled did not detail 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 manager and staff confirmed that routines in the home were as flexible as possible and residents were encouraged to undertake activities inside and outside the home. Mealtimes were flexible and could be changed when the resident requested. Times for getting up and going to bed were based on the preference of the resident and this was observed on the day. The manager confirmed that the home does not act as appointee for any of the residents living there. The residents spoken with on the day were not aware of Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 14 the advocacy service, as this information was not displayed in the home. The manager confirmed that arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions were available. Routines observed in the home were flexible and residents’ individual choices were addressed. Staff encouraged residents to leave the home with relatives and friends. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Broome End has a clear and robust system in place that ensures the protection of its residents in the event of an allegation of abuse. EVIDENCE: The home had a clear and comprehensive Protection of Vulnerable Adult (POVA) policy available to staff. The home has formal guidelines to advise staff on the procedure to take in the event of an allegation of abuse being made. Broome End has a Whistle blowing policy available to staff to help them to bring up any issue that they have concerns about without repercussions. The home had no allegations of abuse to date. Evidence seen on the day confirmed that the home had a planned programme of training for staff on the issue of the Protection of Vulnerable Adults, all staff currently working in the home have received this training. On discussion with the manager it was noted that the current training time provided on this issue was 2 hours and there was some concern that this was not long enough for staff to absorb, discuss and reflect on this issue. The manager was able to discuss the procedure both she and her staff would follow in the event of an allegation of abuse being made. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected – please see previous report. EVIDENCE: Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. The recruitment procedure in the home was not robust and did not provide the safeguards to ensure that appropriate staff were employed, potentially putting the residents at risk. EVIDENCE: The three staff personnel files examined did not contain information necessary to ensure the safety of residents through the recruitment process. Two files did not contain the two required references. Two staff file did not contain a Criminal Reference Bureau check and the references attached did not contain enough information regarding the skills and knowledge of the individual. One of the staff had started work without their CRB but tis had been received by the time this inspection took place. This issue was discussed on the day, and the manager was reminded that staff must not commence employment until all of the appropriate documentation was in place. There is a requirement made regarding this issue and this may be found below. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 Broome End has a competent, reliable and professional manager who is fit to meet the purpose of the role. EVIDENCE: The staff on the day confirmed that they were confident in the skills of the manager. The manager has built good relationships with the staff team. The manager Donna Masson has 20 years experience as a nurse and had been the registered manager of Broome End for the past 5 years. The manager had signed up to undertake the NVQ Level 4 in September 2004 and was near completion (December 2005). The manager informed the inspector that she was leaving Broome End in January 2006. Ashbourne Healthcare has not advised the CSCI of this issue. Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 19 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 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 20 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 Timescale for action The registered person must 31/12/05 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 28.11.05. The registered person must 28/11/05 ensure that the home does not admit any prospective resident without receipt of a social services assessment. The preadmission assessment document must contain in detail, the full range of the prospective residents care needs. The registered person must 28/11/05 ensure that resident care plans contain information on all aspects of care. The care plans must include a completed risk assesment. Care plans must be reviewed on a regular basis with the involment of the resident and/or representative. DS0000017785.V272570.R01.S.doc Version 5.0 Page 21 Requirement 2. OP3 14 (1) 3. OP7 13 (4), 15 (1) & (2) Broome End Care Centre 4. OP8 12 (1) 5. OP12 14 (1) (a) (c) 6. OP29 7, 9, 19 Sch2 7. OP19 23 (1) (a) 8. OP33 24 (1) (a) The residents’ care plans must include information with regard to all aspects of helath care, oral care and hygiene. The registered person must ensure that the home provides the residents with a full range of stimulating social activity based on the assessed needs of the resident group. The registered person must ensure that staff are not employed until the home is in receipt of all of the information required under this regulation. This is a repeat requirement. 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 consider securing this area until the above action is carried out. This is a repeat requirement. The registered must ensure that the homes 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. 28/11/05 31/12/05 28/11/05 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Broome End Care Centre DS0000017785.V272570.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex 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 DS0000017785.V272570.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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