Inspection on 12/06/07 for Broomgrove Nursing & Convalescent Home

This inspection was carried out on 12th June 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

Broomgrove Nursing &... 03/03/06

Broomgrove Nursing &... 20/09/05

Broomgrove Nursing &... 12/01/05

Broomgrove Nursing &... 10/06/04

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

CARE HOMES FOR OLDER PEOPLE Broomgrove Nursing & Convalescent Home 30 Broomgrove Road Sheffield South Yorkshire S10 2LR Lead Inspector Marina Warwicker Key Unannounced Inspection 12th June 2007 10:20 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 DS0000021772.V331349.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. DS0000021772.V331349.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broomgrove Nursing & Convalescent Home Address 30 Broomgrove Road Sheffield South Yorkshire S10 2LR 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) 0114 266 1311 0114 268 4276 enquiries@broomgrove-trust.co.uk The Broomgrove Trust Post Vacant Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (36) of places DS0000021772.V331349.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 Brief Description of the Service: Broomgrove Trust Nursing and Convalescent Home with Sheltered Housing is a registered charity established in 1964 to meet the needs of older people in Sheffield. Individualised nursing care is provided in a warm and supportive environment, by a well established, skilled and committed team of nurses and care assistants who are particularly experienced in caring for people who need recuperation. The home provides convalescent care for those who have recently been in hospital and respite care for people whilst their family or carers take a holiday; it also offers a number of places for permanent care. DS0000021772.V331349.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on Tuesday 12th June 2007 between 9.30am and 4pm. Seven people who use the service, a visiting professional, three relatives were consulted and six staff were spoken to. A further twelve people living at the home/ relatives, fifteen staff and three visiting professionals were contacted by post to obtain feedback about the service. Comments received from the surveys have been included in the body of the report. Time was spent observing and interacting with staff and the people living at the home. The manager was present during the inspection. The premise was inspected which included bedrooms of the people living at the home and the communal areas inside and the outdoors. Samples of records were checked. Care plans, medication records, some service reports and staff recruitment and training files were checked. The fee for a week was £630 at the time of the site visit. I would like to thank the people living at the home, the relatives, the staff and the manager for their contribution towards this process. What the service does well: Prospective people and their representatives who wish to use the services at Broomgrove have the information they need to make an informed choice. The staff assure them that they are able to meet the identified needs of the people who wish to move into the home. The people have their needs assessed and a contract is drawn, which states the type and the standard of service they will receive at the point of moving into Broomgrove. The health and personal care that people receive at Broomgrove is based on each individual’s assessed needs. The principles of respect, dignity and privacy are put into practice by the staff that work at the home. People who use the services at Broomgrove are able to make choices about their life style. The staff support the people to maintain their life skills. DS0000021772.V331349.R01.S.doc Version 5.2 Page 6 The meals served on the whole are appealing and have good nutritional value. People who use the service are able to express their concerns and have access to an effective complaints procedure. The people who live in Broomgrove are protected from abuse, and have their rights protected by competent staff. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. Staff employed at Broomgrove are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions. The appropriate staffing levels help with the support and care of the people who live at Broomgrove and also facilitate the smooth running of the service. The management and administration of the home is based on openness and respect for those who use the service. The manager and her team have developed an effective quality assurance system to measure and monitor the standards of care and support they offer to those who live at Broomgrove. What has improved since the last inspection? What they could do better: The interests of individuals living at the home need to be recorded in their care plans. Opportunities for stimulation through leisure and recreational activities in and outside the home must be organised, which need to reflect the needs, preferences and the capacity of those who reside at Broomgrove. Up to date information about the activities must be circulated to all the people in the appropriate formats. The cook needs to consult the people living at the home when the menus are drawn up. Snacks and drinks must be made available at all times and the people need to be made aware of this. The staff must ensure that those who need help at meal times are offered assistance without delay. DS0000021772.V331349.R01.S.doc Version 5.2 Page 7 Sufficient numbers of staff need to be available at meal times to avoid meals being served cold. The programme of renovation and refurbishment must be followed through as planned. This must include the renovation of the kitchen. The people living at the home need to feel that they could have a shower or a bath when they want. Therefore the bathing and showering facilities available to people need to be improved. All staff must receive formal induction training within the first six months of their appointment, which equips them to meet the needs of the people they are to care for. The manager is in the process of reviewing the programme. The manager must continue the quality audits and the Responsible Individual needs to monitor progress during the monthly visits. The Responsible Individual must produce a written report each month on the conduct of the home. From the evidence gathered during the inspection process it is clear that the new management are reviewing and revising areas of practice, training and facilities. They have drawn out action plans and these were shared with the Commission for Social Care Inspection officer. Although requirements have been made these are already being addressed by the management of the home. 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. DS0000021772.V331349.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 DS0000021772.V331349.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, 2, 3, 4 and 5. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Prospective people and their representatives who wish to use the services at Broomgrove have the information they need to make an informed choice. The staff assure them that they are able to meet the identified needs of the people who wish to move into the home. The people have their needs assessed and a contract is drawn, which states the type and the standard of service they will receive at the point of moving into Broomgrove. EVIDENCE: The people living at the home and their representatives said that information about the facilities was available upon request. The feedback from the surveys by the Commission for Social Care Inspection confirmed this. One person DS0000021772.V331349.R01.S.doc Version 5.2 Page 10 commented, “We knew the home had a good name for its standard of care and that was enough for us.” There was also a comment that since the purpose of admission was to recuperate, the family and the person were not made aware of the set up at the home when transferred from the hospital. The manager was informed of the comment. A copy of the statement of purpose & the service user guide were obtained at the site visit. It was written in jargon free language and had information for the relevant client groups. The manager said, that she was in the process of formalising the documentation and will be displaying it in the reception areas following the planned refurbishment. Three people said that they had contracts with the Trust and their families had the documents. There were two types of contract seen; one was for people accessing respite and the other was for those in for permanent stay. Two staff and five relatives informed us that the individuals were admitted following an assessment of their needs by the nurses at the home. They said that the staff consulted the other professionals involved in the individual’s care before agreeing admission to Broomgrove. The families also said that every person had a care plan and that the staff were happy to discuss any of their concerns. However, one person said that s/he had not seen the care plan. The manager was made aware of this comment. Although the staff encouraged people to visit the home before moving in, most permanent residents were those who used the respite service before or had been in Broomgrove for convalescence. DS0000021772.V331349.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 and 11. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The health and personal care that people receive at Broomgrove is based on each individual’s assessed needs. The principles of respect, dignity and privacy are put into practice by the staff that work at the home. EVIDENCE: Three care plans were checked and six staff were interviewed. Direct observation of care on the day of the site visit and the comments from the surveys have been used to measure this outcome area. The care plans had been devised from the needs assessments and in the majority of cases with the help of the person and their relatives. There was evidence that the care plans had been reviewed by the staff regularly. However, the management are in the process of revising the whole ‘care plan’ DS0000021772.V331349.R01.S.doc Version 5.2 Page 12 documentation so that it should be upgraded in line with the relevant clinical guidance. The management have improved the link nurse systems for tissue viability and continence care. As a result of the audits carried out by the management, further mattresses, hoists and pressure relieving equipment have been purchased. On the day of the site visit no one was self-medicating at the home. The staff said that this was due to the preferences of the people and also their capacity. Three Medication Administration Sheets were checked. The recordings were satisfactory. It was recognized that the nurses were responsible for the administration of medication. It was noted that one of the people was receiving different categories of pain relief for the condition. The timing of the medication administration could have been revised to ensure the maximum effect of the medication over the 24hour period. The nurse who helped with the medication check was made aware of this. During conversations the care staff said that they were interested in finding out how to recognise the effects of medicine and to identify any side effects. Discussion took place with the manager and it was agreed that care staff are in the frontline and such information should be readily available to the key workers. The people who were using the service said that the management of care ensured that the staff respected their privacy and dignity at all times. These are some of the comments received. “My mother is always immaculately clean. They employ a good quality of professional staff.” “The staff are very caring and considerate.” “Although the client group has changed and there are more bed bound and confused people the staff make sure they make time for everyone. The staff always show respect for the old people and speak to them in a friendly manner and with respect.” Four staff said that they had attended Palliative care training where they had received information on how to care and comfort those who were dying and offer support to the relatives. One relative said, “The nurses supervise the care staff and between them they make sure that they look after the very ill individuals and their families.” DS0000021772.V331349.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use services at Broomgrove are able to make choices about their life style. The staff support the people to maintain their life skills. Social, cultural and recreational activities could be improved to reflect the expectations and preferences of those who reside at the home. The meals served on the whole are appealing and have good nutritional value. EVIDENCE: The following are some of the remarks from the surveys. “Could do with more activities for all to join in.” “My talking books and radio are my lifeline. But have difficulty receiving my books regularly.” “At the moment there are no stimulations for residents.” “The home has just started an exercise to music class weekly – that is it.” DS0000021772.V331349.R01.S.doc Version 5.2 Page 14 “One religious service every 3 weeks – not on a Sunday- Good to be on a Sunday.” “It would be good to have a coffee morning or some activity where the residents could get to know each other. This will give the relatives an opportunity to join in.” “Little interaction occurs now. Why don’t staff encourage the older people to come out of their rooms and mix.” These comments were shared with the manager. The manager said that she had realised that people needed suitable stimulation and that she had encouraged people living in Broomgrove to suggest and lead activities. She also discussed the variety of activities she was trying to organise for the people. The manager said that she would take on board the comments made above when organising activities. Four people who live at the home and three staff said that visitors were received at any reasonable time. The visitors were able to spend time in private. The staff said that they help people maintain their community contacts if they so wish. During the tour of the premises it was noted that most people had some personal possessions in their bedrooms. People who were able to manage their own finances did so themselves. The relatives or the advocates helped those who lacked capacity. The people were observed having lunch in the dining room and the inspector had the same meal on the day of the site visit. The lunch was appealing and tasty. Four people said that they received three main meals every day and that they could ask for snacks if they wanted. One person said that her relatives always brought in snacks when they visited and this was what she ate in between meals if she wanted anything. The following comments were received from the surveys and the manager was made aware of this on the day of the site visit. “More thought to dietary needs. More tailor-made meals for individuals. More training for staff and more help cutting up food at meal times.” “Little choice of meals. Monotonous meals. At 5pm a crumpet or a sandwich and soup, sometimes cheese on toast or toasties etc. This has to last till 8am next day far too long.” “Very happy with the home and my mother gets good meals.” “I feel extremely satisfied with all aspects of their care including the meals served at the home.” DS0000021772.V331349.R01.S.doc Version 5.2 Page 15 “Could have fresh fruit more available for the people in the communal areas. The staff should encourage them to have fruit at snack times.” “Can the menus be varied.” “Sometimes if the staff are not on the ball they could end up forgetting to serve the tables then we are given cold lunch.” On the day it was observed that the mealtime was organised well. There was adequate staff around so that they were able to take meals to individuals’ bedrooms, assist those who needed feeding and serve meals to those who came to the dining room promptly without the meals getting cold. The manager agreed that she had already identified the shortfalls in this area and not only had she appointed a new cook but also continued to monitor the improvement by carrying out monthly audits. The inspector saw the evidence of audits and action plans. DS0000021772.V331349.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service are able to express their concerns and have access to an effective complaints procedure. The people who live in Broomgrove are protected from abuse, and have their rights protected by competent staff. EVIDENCE: There was a complaints procedure for those who wish to register concerns or make formal complaints. The staff said that depending on the complaint they try to correct it without delay to avoid further problems. The staff also said that however small the complaint was they always informed the nurse in charge. The manager had records of any formal complaints, the action taken by the home to investigate and rectify them. The manager said that all concerns were treated seriously however small it may perceived to be and that the staff team took positive action by learning from them. Those staff who were interviewed had attended training on Protection Of Vulnerable Adults. The staff were aware of the different types of abuse and the action they needed to take if they witnessed any form of abuse. DS0000021772.V331349.R01.S.doc Version 5.2 Page 17 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, 22 and 26. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables people who use the service to live in a safe and comfortable environment, which encourages independence. Some parts of the home are in need of renovation and refurbishment. Washing and bathing facilities are not adequate to meet the needs of those who use the service. EVIDENCE: The location and the layout of the home reflected the purpose of the home. It is comfortable and homely and the people who live at the home said that they were settled and comfortable. The manager said that a programme of renovation and refurbishment had been agreed and that work had commenced in one of the empty bedrooms. DS0000021772.V331349.R01.S.doc Version 5.2 Page 18 The grounds were kept reasonably tidy. However, further work outdoors would give people extra room to relax. The people enjoy the central patio/garden area. This was well maintained with seating arranged for people to sit out There was ample shared space for the people. These were some of the comments received from the people who use the service and their relatives. “Nylon bed covers are very uncomfortable.” “With only one bathroom it is only possible to have two baths a week. Prefers to have a shower or a bath every day but this is not possible due to the facilities.” “They keep the home clean and free of smells.” “The routine of the home is very good.” “Layout is good. But could do with some refurbishment.” “More up to date washing facilities for people.” “Upgrade the bed linen.” The manager accepted the comments and said that as part of the refurbishment they were to replace bed linen. There were plans to increase the bathrooms and en-suite facilities. The managers comments were supported by documentary evidence held at the home. The people were able to access all parts of the home through the provision of passenger lift and ramps. The kitchen was in urgent need of renovation and brought updating. There has been an Environmental agency inspection in February 2007. The issues highlighted must be actioned. The agency had commented that the standard of cleanliness of the kitchen at Broomgrove was ‘excellent’. The premises are kept clean and free from offensive odours at all times. The laundry facilities were sited away from the food preparing and serving areas. DS0000021772.V331349.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Staff employed at Broomgrove are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions. The appropriate staffing levels help with the support and care of the people who live at Broomgrove and also facilitate the smooth running of the service. EVIDENCE: On the day of the site visit there were adequate numbers of staff and the skill mix was appropriate to the needs of the people living at the home. The records of the staff rota demonstrated that there were sufficient numbers of staff allocated over the 24hour cycle. Domestic staff had been employed in satisfactory numbers to ensure that standards of cooking and cleaning activities were maintained. The following are some of the comments received by the Commission for Social Care Inspection. “All the staff are very helpful.” “Very friendly and helpful staff.” “Some staff would benefit by training how to help older people. They seem a little hesitant or even not sure.” DS0000021772.V331349.R01.S.doc Version 5.2 Page 20 “They employ good quality of professional staff. Staff: Patient ratio is high compared to other nursing homes.” “The staff don’t always come when summoned. They arrive eventually.” “A little confused as to the different ways of doing things when not used to working in a nursing home. We could benefit by cultural updates.” “The skill/ gender mix is not good. Need more staff.” “The staff are very caring, considerate and polite. The people are addressed as Mr or Mrs and not by their first names.” “Good training opportunities and better teamwork now the new management have settled in.” As a response to the above, the manager said that she has been recruiting staff to achieve the correct gender mix. The nurses said that they always approach the people to find out their preferences when it comes to delivering personal care. The manager identified the need for customer care training and Ethnicity and diversity training since the staff employed at the home are from diverse backgrounds. Four staff files were randomly selected and checked. It was confirmed that the manager operated a thorough recruitment procedure and the information held on the files supported this. Three staff during formal interview explained how they went about getting a job at the home and this complied with the Care Home Regulations 2002. The manager said that the staff received the basic mandatory training and that the Trust was in the process of reviewing and revising the staff learning and development opportunities. This is to enable staff development and also for the home to achieve its aims and objectives so that it is able to meet the changing needs of the people who live at Broomgrove. DS0000021772.V331349.R01.S.doc Version 5.2 Page 21 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, 36 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management and administration of the home is based on openness and respect for those who use the service. The manager and her team have developed an effective quality assurance system to measure and monitor the standards of care and support they offer to those who live at Broomgrove. EVIDENCE: The manager is a qualified, competent and experienced person to run the home and she aims to meet the stated purpose. The manager and the nurses attend regular training to keep up their skills and knowledge. During the staff interviews the following comments were received. DS0000021772.V331349.R01.S.doc Version 5.2 Page 22 “When patients come with special needs such as needing Halal diet, people with learning difficulties and Downs syndrome also from different cultures, the nurses are very good at preparing us so that we feel confident in dealing with them.” “ I have worked in other places. I can tell you the care here is wonderful and the team work is smashing.” “The nurses are good at supporting and supervising us. We feel happy to approach them and ask if we want.” The management have introduced quality-monitoring systems based on seeking the views of the people who use the service and those who work at the home. Although there was documentary evidence of the audits carried out; the process is in its infancy and the Commission for Social Care Inspection would like the monthly visit by the Responsible Individual to reflect the progress made by the quality assurance programme in the -Regulation 26- reports. The manager said that formal supervisions had been introduced and this was verified during the staff interviews and whilst checking staff files. The management of the home had ensured as far as is possible the health, safety and welfare of the people who live and work at the home. The staff were aware of reporting all accidents, injuries, incidents of communicable diseases and all deaths at the home. The manager informed the Commission for Social Care Inspection via the pre-inspection record that all services and checks of Gas, Electricity and equipment maintenances were up to date. The induction training too has been reviewed to reflect the Skills for care national standards. One of the staff surveyed suggested that, “The staff Induction is a couple of weeks. This was working with another person. There was no formal training programme.” During the staff file checks the four staff selected had followed an induction schedule and the senior staff had signed to indicate that the persons were competent in the specific areas. All four staff checked had records of supervision by their line managers. Three staff during interview confirmed this. DS0000021772.V331349.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 2 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 3 DS0000021772.V331349.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NA 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 OP12 Regulation 16(2)(m) &(n), 16(3) Requirement The interests of people living at the home must be recorded in their care plans. Opportunities for stimulation through leisure and recreational activities in and outside the home must be organised, which must reflect the needs, preferences and the capacity of those who reside at Broomgrove. Up to date information about the activities must be circulated to all people in the appropriate formats. The people must be consulted when the menus are drawn up. Timescale for action 14/08/07 2 OP15 12,16&18 14/08/07 3 OP19 16 Snacks and drinks must be made available at all times and the people must be made aware of this. The staff must ensure that those who need help are offered assistance without delay. There must be sufficient numbers of staff available at meal times to avoid meals being served cold. The programme of renovation 06/11/07 and refurbishment must be DS0000021772.V331349.R01.S.doc Version 5.2 Page 25 4 OP21 23 5 OP30 12&18 6 OP33 26 followed through as planned which must include the renovation of the kitchen. All the people must have access 16/10/07 to appropriate bathing and showering facilities so that people are able to choose the frequency for baths and showers. All staff must receive formal 16/10/07 induction training within the first six months of appointment, which equips them to meet the needs of the people they are to care for. Those staff who had not had formal induction must follow the programme during their supervision. The manager must continue the 14/08/07 quality audits and the Responsible Individual must monitor progress during the monthly visits. The Responsible Individual must produce a written report each month on the conduct of the home. 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 DS0000021772.V331349.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000021772.V331349.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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