Inspection on 20/08/07 for Broome Park Nursing Home

This inspection was carried out on 20th August 2007.

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

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

Other inspections for this house

Broome Park Nursing Home 24/04/06

Broome Park Nursing Home 05/01/06

Broome Park Nursing Home 18/07/05

Broome Park Nursing Home 21/01/05

Broome Park Nursing Home 23/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Sutton Lodge Nursing Home

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOMES FOR OLDER PEOPLE Broome Park Nursing Home Station Road Betchworth Surrey RH3 7DF Lead Inspector Suzanne Magnier & Lesley Garrett Unannounced Inspection 20th August 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 Park Nursing Home DS0000013303.V345761.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 Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broome Park Nursing Home Address Station Road Betchworth Surrey RH3 7DF 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) 01737 843333 01737 842444 Mr Michael Law Hing Choy Mrs Muriel Law Hing Choy Mr Michael Law Hing Choy Care Home 56 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (43), Learning disability (3), Learning disability of places over 65 years of age (3), Mental disorder, excluding learning disability or dementia (9), Mental Disorder, excluding learning disability or dementia - over 65 years of age (43), Physical disability (9), Physical disability over 65 years of age (12), Terminally ill over 65 years of age (4) Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Age/age range - up to 9 (nine) service users within categories, dementia DE(E), learning disability LD(E), physical disability PD(E) over 65 years. Of the 56 service users accommodated up to 43 may fall within category of either mental disorder MD(E) or dementia DE(E) - over 65 years. Up to eight service users within all categories (except category TI(E)) may be accepted on a day care basis. One (1) terminally ill person over 65 years of age (TI(E)) within category (MD(E)) or (DE)(E)) may be admitted to the Annex Three (3) persons with physical disability over 65 years (PD(E)) within categories (MD(E)) od (DE(E)) may be admitted to the Annex. One person with Mental Disorder, excluding learning disability or dementia (MD) over 60 years of age may be admitted to the Annex One (1) person with Dementia (D) over 60 years of age may be admitted to the Annex 24th April 2006 Date of last inspection Brief Description of the Service: The nursing home consists of two separate buildings, one that is Broome Park and the other Stable Cottage. Both homes are privately owned and specialise in the care of older people with enduring mental health disorders, dementia and individuals with physical or learning disabilities. The homes operate from a converted country manor house and stables, set in 10 acres of mature, well maintained grounds. The accommodation consists of single and twin bedrooms, some with en-suite facilities, communal lounges, sitting rooms and separate dining rooms. Access to the upper floors is via stairs and a lift. The home is situated in a semi-rural location and is accessible by major road and rail networks. It is convenient for Dorking and Reigate town. The home has its own vehicles and drivers who convey residents to appointments and other community resources. The current fee is £750.00 per week. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier and Mrs L Garrett, Regulation Inspectors, carried out the inspection and divided the inspection process between Broome Park and Stable Cottage. The owners, the head of care, the Stable Cottage manager and the two managers from Broome Park represented the home. For the purpose of the report the individuals using the service are referred to as people/individuals living in the home. The inspectors arrived at the service at 09.30 and was in the home for six hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspectors spent time talking with people living at the home in order to seek their views about the home and the care they receive. Responses to questionnaires that the Commission had sent out and the written comments have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has, in this report, made judgements about the standard of the service. Documents sampled during the inspection included the home’s Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records and several of the service’s policies and procedures. Following the previous key inspection in April 2006 the service has met all the requirements made. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 6 The inspector would like to thank the people living in the home, the staff and the managers for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The home has started to improve the care plans to incorporate a more holistic approach to the person receiving care and support in the home. The home has undertaken a total refurbishment of the main lounge area, involving people living in the home, their relatives and representatives in choosing colour schemes and soft furnishings and purchasing a flat screen television. The home has introduced indoor plants and other household ornaments, and framed pictures to make the home more homely. Arrangements have been made for a visiting bi-annual clothes sale from an external retailer to come to the home. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 7 The home has restructured the management tier with the appointment of a new nurse manager and the creation of a new post of deputy nurse manager at Broome Park. There has also been an increased staff compliment in all areas of 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 Park Nursing Home DS0000013303.V345761.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 Park Nursing Home DS0000013303.V345761.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): 1, 3, 5, 6. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The information which people have in order that they can make an informed choice about moving to the home needs to be further developed. The home’s admission and assessment procedures ensure that individual’s needs are appropriately identified and met. People are encouraged to visit the home prior to residency. EVIDENCE: The inspector was shown the home’s Statement of Purpose and Service User Guide and three attractive postcards of the home, which were a combined document called The Summary of the Statement of Purpose. The inspector has required, as per the Care Homes Regulations 2001 (updated July 2006), that the document be reviewed and developed into two documents, one, which is known as the Statement of Purpose and the other the Service Users’ Guide. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 10 In discussion with the home’s representatives during the inspection it was agreed that the service users’ guide could be developed into a simplified document which would be more accessible to individuals in order to inform them or prospective individuals or their representatives about the services provided by the home. The inspector sampled three individual’s files at Stable Cottage. Two of the files were for individuals who were due to be admitted to the home on the day of the inspection. Each of the three files contained a documented pre-admission assessment about the care and support needs of the individual. The manager and the Annual Quality Assurance Assessment (AQAA) advise that the pre-admission assessment for individuals is undertaken by the senior care home staff, so that all prospective individuals have their needs assessed in order to ensure that the home can meet their needs. The home had sought written assessments from social and health care teams, and the inspector evidenced that some assessments had been completed with the support from a relative or representative, prior to the individual’s admission to the home. Prospective individuals are encouraged to visit the home and meet with other people living in the home and the staff. The home does not provide intermediate care. A comment received stated, ‘I had a visit to Broome Park Nursing Home before deciding to stay. I had received enough information’. Broome Park Nursing Home DS0000013303.V345761.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, 10. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The health and personal care that people receive is based on their individual needs as set out in their care plans. Further development of risk assessments need to be made to ensure the safety of people in the home. Medication procedures ensure that medication is administered to all individuals in a safe and appropriate way. People’s dignity and respect is promoted. EVIDENCE: Written comments received by people regarding the care received at the home included ‘the medical care seems to be extremely good. The manager and nurses and Mr Choy, the owner, are efficient, kind, diligent and caring’. I am happy with the care here, all the staff help with my personal care and are available all the time’. ‘I am very satisfied with the medical support in the nursing home. I like the GP and he is very helpful’. ‘The perspective of the relatives isn’t always realistic - but the staff always appear willing to talk issues through and try to resolve points of concern’. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 12 The inspector sampled two individual’s plans of care and found them to contain well-documented care plans. The plans included the preferred name of the individual, their next of kin or significant person, the individual’s photograph, documents regarding medication, their GP (general practitioner) and any other health care professional support. The individual’s choices regarding gender specific care, their support needed regarding personal care, sleeping patterns, their emotional, nutritional needs and preferences. It was evident that the care plans were kept under review to reflect the changing needs of the individual, and the daily notes were well written to reflect people’s rights to dignity and respect, and reflected the care and support offered and provided by staff. During the sampling of the care plans it was noted that a development to the plans could include a more person-centred approach. One of the managers in Broome Park advised that the home’s activity co-ordinator and the manager had started to collect information from individuals, their relatives and friends in order to collate a biography of the person. The inspector sampled a completed biography, which included a great deal of information and also photographs of the person throughout their life before retirement. This was viewed as good practice in order that individuals receiving care and living in the home are supported in a more holistic way. Whilst sampling the care plans the inspectors noted that the home’s risk assessments generally consisted of a tick box system and included risk assessments regarding people falling, moving and handling, the use of bedrails and wheelchairs. It has been required that the risk assessments be further developed to include more detail regarding the hazards being presented and what actions the home has taken, as far as reasonably practicable, in order to safeguard individuals from harm. Whilst touring the premises it was noted that people moved freely around the home. The inspector noted that one individual was calling out and looked in a dishevelled state. The staff member at hand explained that the individual found it difficult to settle at times, which resulted in them testing the service. The inspector asked about the person’s loss of dignity with regard to their dishevelled state and the staff member advised that the home continued to work closely with the individual’s relatives to discuss this concern and possible changes to the person’s attire, yet the individual did not want to wear trousers or have a blanket on their lap. This information was later confirmed with the manager and it has been recommended that, where a loss of dignity has been recognised by staff and there is a lack of consent by the individual to address this concern, a risk assessment and guidelines are implemented which clearly illustrate that the home is aware of these matters and there is documented Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 13 evidence to support that the home has made effort to address the concern in order to promote the respect and dignity of the individual. The manager explained that the home has strong links and support from the home’s general practitioner (GP) who visits the home on a weekly basis. The managers advised that there is good health care support from other practitioners, which includes opticians and chiropodists, Macmillan nurses, tissue viability nurse, dentist, physiotherapist, dietician support and attendance at specialist clinics. The inspector noted that files contained records detailing healthcare professional visits to evidence that individuals received ongoing support to ensure that their healthcare needs were met. One inspector discussed the medication procedures within the home. It was observed that the home dispenses their medication from bottles and the medication administration record (MAR) lasts for three months. The MAR charts have to be handwritten by two members of staff and this process can be time consuming, according to the staff spoken with. Medicines are delivered to the home every month from the local pharmacy but are in bottles and not in blister packs. A discussion took place with the nurses who administer the medicines about the possibility of changing to blister packs, as this will then mean that the pharmacy will print the MAR charts each month for the home. Following the inspection a meeting took place with representatives of the home to enable the inspectors to feed back their findings and the staff present all agreed that they would investigate the possibility of changing to a blister pack system. The staff stated that the GP reviews all medications every year and more often if it is necessary. During the inspection it was noted that there was generally a calm atmosphere throughout the home. Staff addressed people in a professional and caring manner. Individuals were addressed by their first or full name and, where appropriate, names of endearment were used to support trusting relationships. Staff were observed to preserve and maintain people’s dignity and privacy by knocking on their room doors and waiting to enter, supporting people discreetly to the bathroom and being observant and attentive to people who were not fully able to maintain their own dignity. Quiet areas in the home were available to people to use. A comment received from a healthcare professional stated, ‘Few residents are able to communicate any difficulties, but from the limited observation it would appear that their dignity and privacy is always respected’. Broome Park Nursing Home DS0000013303.V345761.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, 15. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. People who use the service are able to exercise choice in their daily lives, maintain bonds with family and friends and take part in social, cultural, religious and recreational activities. The home provides a healthy and balanced diet in a pleasant spacious dining area. However, further improvements need to be made with regard to staff engagement with individuals at mealtimes. EVIDENCE: The inspector’s spoke to a variety of people during the day, all of whom spoke highly of the activities, staff and general running of the home. It was noted that people were moving freely around the home and the pace of the home was suitable to the needs of the individuals. The inspector noted that some people in Stable Cottage enjoyed sitting in small groups by the patio doors, looking out onto the courtyard. The people were doing a variety of activities, which included knitting, reading the daily paper, chatting with each other and enjoying their coffee and biscuits. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 15 One inspector spoke with the activities organiser who has worked at the home for fifteen years. She has worked in her current role for four years and has recently completed an activities course at a local college. On the day of the site visit the people who use the service were participating in ball games. There is a programme of activities published for the month and it is displayed on the notice board. The activities organiser stated that she is in the process of writing to the families and requesting information to enable her to compile life histories for the individuals. She also said that she is about to start documenting how each individual partakes in the activities. The home also has good local community links and active support from “The Friends of Broome Park” charity. The home owns an ambulance (with tail lift) which is used by all individuals at the home to undertake regular social activities and pursuits. All individual’s birthdays are celebrated with a cake and a gift from the home. Weekly sessions with complimentary therapists are available and monthly visits from local religious organisations are also avaialble. External performing agencies provide an entertainment programme and an annual garden party is held, plus 1:1 and group outings. The hairdresser visits every week and there is also a gentle exercise class, which individuals can attend. Comments received by the Commission regarding the activities available in the home included, ‘Provide more to stimulate the able-bodied from becoming bored’, ‘I try to take part in the home’s activities’, ‘I like the shows and activities organised by the home’, ’I do enjoy the show organised by the home, it is quite nice. I would like to go out more often’. The AQAA received by the Commission detailed that there are no restricted visiting hours for friends and relatives and the home has an Open Door approach for visitors. The inspectors observed that people were able and had facilities to visit their relatives and friends in privacy. The AQAA received by the Commission detailed that the home has oongoing consultation with Sodexho (the catering provider) regarding the meal planning and nutritional issues for the home, and the chef manager had recently received a national award. The home continues to offer a range of food and menu choices based on seasonal produce that is freshly cooked and prepared on site and the specific dietary requirements for individuals are assessed and catered for, and there is daily face to face contact between the chefs and individuals in the home. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 16 The inspectors observed the breakfast and midday meal throughout Broome Park. The inspectors observed that the dining area was well decorated, bright and spacious and the dining tables were pleasantly arranged with napkins, tablecloths, appropriate cutlery and condiments of choice. Some individuals were enjoying their meal using their fingers whilst others preferred to use the cutlery available. The manager explained that the pace of the dining experience had been slowed down in order to meet the needs of all people in the home during mealtimes. In general staff were supportive and engaged with individuals with discretion and dignity during the mealtime. However, on one occasion a staff member was observed by the inspectors to support a person with their breakfast cereal by standing by the person and not speaking to the individual to state that they were going to support them to eat their cereal, and offered no explanation of what the cereal was and offered no encouragement to the individual with regard to eating their meal. It has been required that the home must at all times ensure that the provision of care, support and supervision for individuals during mealtimes ensures that individual’s needs, respect, dignity and safety is promoted. Following the morning feedback session to the managers this shortfall was brought to the managers’ attention. It was evident that the managers were disappointed with this feedback as they explained that there had been a concentrated effort to support staff with training and mentoring the importance of dignified and sensitive support for people at mealtimes. During the lunchtime meal it was observed that all staff supporting people with their meals were sitting down and openly engaging and encouraging people with their meals. The inspectors met with the home’s deputy chef who was also seen to engage positively with the people in the dining area whilst he was serving the meals. The meals served were hot, pleasantly presented and enjoyed by individuals. It was noted that one individual with a pureed diet had their meal presented on a divided platter which ensured that the meal remained separate and looked appetising. People spoken with during and after their meal stated that they had enjoyed their meal. The Commission had received a variety of written comments regarding the quality of the meals served in the home and these included, ‘I have no direct experience but from what I hear the standard of the food is not as good as it could be’, ‘By all accounts the food is excellent and staff are caring and sympathetic to patients’ requirements’, ‘The meals are very nice, I can always ask for special food of my choice’, ‘Some days the food I don’t like but otherwise I enjoy the food as it is well cooked’, ‘I have choice and the meals are very good and well cooked, I am putting on weight’. Broome Park Nursing Home DS0000013303.V345761.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, 18. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home’s complaints procedures ensure that people are supported to express their concerns and have access to a complaints procedure. Individuals are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The AQAA details that no complaints have been received since the last key inspection. Comments received from people living at the home regarding the complaints process included, ‘I can speak to the staff and the senior staff at the home. I can speak to my sister regularly on my behalf’, ‘I know I can go to speak to the nurse/manager to make a complaint’. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults. Whilst sampling the home policy and procedure regarding safeguarding adults it was noted that a minor adjustment to the policy needed to be made in order to reflect the Surrey local authority multi agency safeguarding procedures of which the home had a copy. The inspectors verified that the home had an understanding of the procedures in Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 18 order to offer an open atmosphere in respect of detecting and reporting bad practice and any allegation of abuse. The AQAA details that there have been no safeguarding referrals under these procedures since the last inspection. The inspector noted that the home has a whistle blowing policy and procedure, which is available to staff in order to safeguard people in their care. The staff training matrix record was in the process of being updated and the head of care advised that all staff receive safeguarding vulnerable adults’ training and, where some staff had not attended the training, plans were in place for the staff to attend the in-house training in order to safeguard people in their care. Broome Park Nursing Home DS0000013303.V345761.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): 19,20,21,24,26. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The physical layout and indoor and outdoor communal areas of the home enable people who use the service to live in a safe and generally well-maintained environment. Individual’s bedrooms suit their needs. The home is clean, pleasant and hygienic. EVIDENCE: Comments received from visitors to the home regarding the environment and cleanliness included, ‘Stable Cottage is not luxurious or ‘posh’ but it is warm and comfortable. There is no money for fresh flowers but everything is tasteful. Comfort and convenience, I would say, are high on the list of priorities’. ‘Some armchairs in the common rooms could be replaced but that is a small matter’. ‘ The home is always clean and tidy, my room is always clean’. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 20 The inspector undertook a tour of the premises and observed that generally the home was well maintained and there was evidence to support that redecoration had taken place within a variety of areas throughout the home. The AQAA advises that the home has a rolling programme of reburbishment and upgrading which includes people’s bedrooms, the garden and main communal areas. The home has employed specialist tradespeople and increased the number of maintenance personnel in order that goals of refurbishment can be achieved. Whilst touring the premises in Stable Cottage the inspector noted that the bathroom on the ground floor was dimly lit and contained a ‘charter of continence’ on one wall with a picture of a sunset on the other. It was brought to the manager’s attention as a recommendation that the bathrooms, including the hairdressing area, throughout the home could be redecorated to reflect a more homely, welcoming and sensory experience for individuals in the home. The inspector observed that the overhead lighting in Stable Cottage was dim yet when individuals living in the home were spoken with they thought that the lighting was sufficient. One person living in Stable Cottage home showed the inspector all the facilities on the top floor and stated that they were generally happy with the home and the services offered. They stated they would like some additional pieces of furniture in their room and had asked the manager for these. This was later confirmed in conversation with the manager. People spoken with in their bedrooms told the inspector that they liked their bedrooms, which were comfortable. It was noted that people’s bedrooms were individualised and some contained their own items of furniture, personal possessions, leisure items including televisions, radios, books and equipment to promote individual’s lifestyles. The home was noted to be clean and hygenic throughout and this standard of cleanliness was brought to the housekeeper’s attention during the inspection. Broome Park Nursing Home DS0000013303.V345761.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, 30. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained, skilled and sufficient in numbers to support the people who use the service. The home has a robust system for the induction, training development and recruitment of staff to ensure people’s needs are met appropriately and safely. EVIDENCE: Comments received regarding the staff included, ’Staff are always very kind’, ‘The home provides good staff’, ‘They seem to have lots of nurses and good carers- all of them so cheerful, happy kind and loving’, ‘Staff are friendly and helpful to the residents’. The inspector was advised that the home is currently supporting 56 individuals and has a total of 47 staff. The manager explained that no agency staff are currently being employed by the home. Staff confirmed that they have regular staff meetings. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 22 The staffing numbers on the day of the inspection were observed to meet the current needs of the people living in the home. Staff members’ views regarding the staffing numbers were positive. It was evident that the home employs a multi-cultural workforce and equality and diversity issues would be addressed, both by people living in the home and the staff. It was observed that on three occasions people who used the service were moved or transferred by staff using an inappropriate technique called a draglift. The inspectors were informed that all staff had received manual handling training and we were assured that all the staff on duty that morning would be spoken to and reminded of the handling techniques used within the home and more training will be given if necessary. Because of these measures no requirement has been made. The inspector sampled two staff recruitment files. All files evidenced that the home undertakes safe vetting practices concerning the recruitment of staff in order to ensure the safety and protection of people living in the home. The staff induction and mandatory training records were not sampled. However, the AQAA advises that a comprehensive in-house training programme three times a week is provided by a qualified nurse educator covering mandatory training, all aspects of care delivery, NVQ studies (Levels 1-4 & A1 assessor), Overseas Nursing Programme & Distance Learning Courses. This information was confirmed with several staff members during the inspection who advised that the training supplied by the home was excellent and staff felt well equipped to do their jobs. The AQQA indicated that twelve staff had achieved their National Vocational Qualification (NVQ) in Care Level 2 or above with 64 of staff working towards achievement of the award. Broome Park Nursing Home DS0000013303.V345761.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, 38. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home is robust and the home is run in the best interests of people who use the service. People’s safety, financial protection and welfare is promoted. EVIDENCE: The atmosphere in the home was calm and orderly. The pace of the home was designed to meet the needs of the individuals living at the home and there was no sense of hurry. It was evident, through observation and talking with people who use the service and staff that the managers had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. The home continues to actively maintain their Investor in People status. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 24 The inspector was advised that no quality surveys had been completed this year and were due to be carried out and that the home will include comments from people’s relatives or represntatives. It is recommended that the home also seeks the views of other visiting professionals to the home. The home does not hold resident or relatives’ meetings but we were told that ‘the friends of Broome Park’ consist of some relatives of the home. The home had a completed catering survey as this is provided by the company that is used by the home. This survey was not dated but the inspectors were told that it was this year’s survey and the outcomes were noted to be favourable. The inspector sampled the system and accounting process regarding the safekeeping of individual’s money and all documentation was accurate and clearly recorded. Health, safety and maintenance records were sampled to evidence that the home undertakes safety checks in order to promote the health, safety and welfare of people in the home. The lids of the clinical waste bins to the rear of the building were noted to be open due to the amount of waste. The managers advised that the collection was due on the day of inspection (Monday) and it was noted by the end of the inspection that external contractors had emptied the bins. Broome Park Nursing Home DS0000013303.V345761.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 3 X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X X 3 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 3 X 2 X 3 X X 3 Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 26 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 4.(1) 5.(1) Requirement Timescale for action 20/09/07 2 OP7 3 OP15 The home’s summary of the Statement of Purpose must be reviewed and developed into two documents, one of which is known as the Statement of Purpose and the other the Service Users’ Guide. 13.(4) The home must further develop 20/10/07 (b)(c) individual’s risk assessments to include more detail regarding the hazards being presented and what actions the home has taken, as far as reasonably practicable, in order to safeguard individuals from harm. 12.1(a)(b) The home must at all times 23/08/07 ensure that the provision of care, support and supervision for individuals during mealtimes ensures that individual’s needs, respect, dignity and safety is promoted. Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP21 Good Practice Recommendations It was brought to the manager’s attention as a recommendation that the bathrooms, including the hairdressing area, throughout the home could be redecorated to reflect a more homely, welcoming and sensory experience for individuals in the home. It is recommended that the home seeks the views of visiting professionals to the home when undertaking the home’s quality assurance surveys. 2 OP33 Broome Park Nursing Home DS0000013303.V345761.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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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